Epidemiology of Epidemiology of Perioperative Bloodborne Perioperative Bloodborne

InfectionsInfections

UCSF Department of SurgeryUCSF Department of Surgery

Grand RoundsGrand Rounds

March 29, 2006March 29, 2006

CaseCase

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

– Sulkowski, MS et al. JAMA 2002 Sulkowski, MS et al. JAMA 2002

Brief OutlineBrief Outline

HIV, Hepatitis B, Hepatitis CHIV, Hepatitis B, Hepatitis C

Surveillance and Reporting SystemsSurveillance and Reporting Systems

Exposure Data from ORExposure Data from OR

Data from Developing CountriesData from Developing Countries

HIVHIVHIV risk from patient to surgeon is lowHIV risk from patient to surgeon is low– No difference in HIV infection between HCW’s No difference in HIV infection between HCW’s

and populationand population

– 138 individuals with probable occupationally 138 individuals with probable occupationally acquired HIV infection: 6 surgeonsacquired HIV infection: 6 surgeons

– 56 HCW’s w/documented seroconversion 56 HCW’s w/documented seroconversion after percutaneous exposure (0 surgeons)after percutaneous exposure (0 surgeons)

– PEP recommendedPEP recommended

Hepatitis BHepatitis B1.25 million people in US w/chronic HBV1.25 million people in US w/chronic HBV

5% of acute HBV -> chronic HBV5% of acute HBV -> chronic HBV

HBV transmission is 30% cases when HBV transmission is 30% cases when naive host has naive host has hollowhollow bore needle stick bore needle stick from chronically infected patientfrom chronically infected patient

Must confirm effective immunizationMust confirm effective immunization– Many surgeons check titers q 10 yearsMany surgeons check titers q 10 years

Hepatitis CHepatitis C4 million in US w/ chronic HCV4 million in US w/ chronic HCV

75% acute HCV clinically occult (like HBV)75% acute HCV clinically occult (like HBV)– 50-80% acute HCV become chronic50-80% acute HCV become chronic– Up to 20% chronic HCV advance to cirrhosisUp to 20% chronic HCV advance to cirrhosis

0.5% rate of conversion after hollow bore 0.5% rate of conversion after hollow bore needle sticks (new data: from 1.8%)needle sticks (new data: from 1.8%)

May require 1 year of testing after May require 1 year of testing after exposure to convertexposure to convert

HCV blood exposure to conjunctiva = HCV blood exposure to conjunctiva = transmission risk of HCV needlesticktransmission risk of HCV needlestick

Worldwide healthcare workerWorldwide healthcare workerto patient transmissionto patient transmission

1991-2005 (Perry et al., forthcoming)1991-2005 (Perry et al., forthcoming)

133 reported total cases of transmission133 reported total cases of transmission– HIV: 2 surgeons-> 3 pts (0.09% pts infected)HIV: 2 surgeons-> 3 pts (0.09% pts infected)– HBV: 12-> 91 pts (2.96% pts infected)HBV: 12-> 91 pts (2.96% pts infected)– HCV: 11-> 39 pts (0.36% pts. infected)HCV: 11-> 39 pts (0.36% pts. infected)

HBV: Surgeon->pt transmissionHBV: Surgeon->pt transmission– Most commonly when e antigen positiveMost commonly when e antigen positive– Many without evidence of injury to handsMany without evidence of injury to hands

Unanswered QuestionsUnanswered Questions

All cases but 1: surgeons transmittedAll cases but 1: surgeons transmitted

One US surgeon transmitted HCV to at One US surgeon transmitted HCV to at least 14 patients: Still operatingleast 14 patients: Still operating

What restrictions should exist for infected What restrictions should exist for infected surgeons?surgeons?

Do we treat blood exposure of a patient = Do we treat blood exposure of a patient = exposure to a HCW?exposure to a HCW?

Federal RegulationsFederal Regulations

OSHA mandates a sharps injury logOSHA mandates a sharps injury log

No requirement to report to state or federal No requirement to report to state or federal bodiesbodies

State and regional reporting systems vary State and regional reporting systems vary greatlygreatly

SurveillanceSurveillanceExposure Prevention Information Network Exposure Prevention Information Network (EPINet)(EPINet)– Dr. Janine Jagger (1991) UVa.Dr. Janine Jagger (1991) UVa.– International Health Care Worker Safety International Health Care Worker Safety

CenterCenter– >1500 US hospitals; 70 facilities>1500 US hospitals; 70 facilities

National Surveillance System for Health National Surveillance System for Health Care Workers (NaSH)Care Workers (NaSH)– CDC (1995)CDC (1995)– 80 facilities in 28 states80 facilities in 28 states

CaliforniaCalifornia

1996 Senate Bill1996 Senate Bill– Sharps Injury Control ProgramSharps Injury Control Program

Voluntary reportingVoluntary reporting

90% of Hospitals report90% of Hospitals report

Weaknesses:Weaknesses:– No reporting of non-sharps injuries (ie No reporting of non-sharps injuries (ie

mucocutaneous exposures)mucocutaneous exposures)– No sample of non hospital-based HCW’sNo sample of non hospital-based HCW’s

Surveillance (ctd)Surveillance (ctd)

Massachusetts Surveillance System for Massachusetts Surveillance System for Sharps InjuriesSharps Injuries– Mass. Dpt Public Health (2001)Mass. Dpt Public Health (2001)– 100 hospitals; required by State Law100 hospitals; required by State Law

VAVA– Automated Safety Incident Surveillance Automated Safety Incident Surveillance

(1998)(1998)

Exposure Data in ORExposure Data in OR

33% (Highest proportion) of hospital-33% (Highest proportion) of hospital-based percutaneous injuries (Epinet 2003)based percutaneous injuries (Epinet 2003)– vs pt rooms, ER, clinicsvs pt rooms, ER, clinics

16.5% (216.5% (2ndnd) for hospital-based non-) for hospital-based non-percutaneous injuries 1995-2001 (NaSH)percutaneous injuries 1995-2001 (NaSH)

Blood exposure events in 6-50% of Blood exposure events in 6-50% of surgical procedures (1997)surgical procedures (1997)

Cuts or needle sticks 1.7-15%Cuts or needle sticks 1.7-15%

Trends: OR lags in preventionTrends: OR lags in prevention

38% drop38% dropin injuries in patient roomsin injuries in patient rooms

(all devices)(all devices)

only only 5.7% drop5.7% dropin OR injuriesin OR injuries

OR PersonnelOR Personnel

Surgeons or 1Surgeons or 1stst assistants (up to 59%) assistants (up to 59%)

Scrub nurses/techs (19%)Scrub nurses/techs (19%)

Anesthesiologists (6%)Anesthesiologists (6%)

Circulating nurses (6%)Circulating nurses (6%)

Exposure in ORExposure in OR

Suture Needles cause the highest Suture Needles cause the highest proportion of percutaneous injuries (up to proportion of percutaneous injuries (up to 77%)77%)– From direct observational study (1992)From direct observational study (1992)– Mostly in muscle and fascial closureMostly in muscle and fascial closure– Especially in using fingers to manipulateEspecially in using fingers to manipulate

Scalpels more likely to cause serious Scalpels more likely to cause serious injuryinjury

Trends in Needle injuriesTrends in Needle injuries

33% decline33% declinehollow bore needleshollow bore needles

27% increase27% increasesuture needlessuture needles

Exposure in ORExposure in OR

Passing instruments hand to hand (16%)Passing instruments hand to hand (16%)

Most self-inflictedMost self-inflicted– But up to 24% by co-workerBut up to 24% by co-worker

Non-dominant hand most common siteNon-dominant hand most common site

Relatively few (<0.05%) are highest riskRelatively few (<0.05%) are highest risk– ie hollow bore needlesie hollow bore needles

Up to 1/3 devices come into contact with Up to 1/3 devices come into contact with patient after HCWpatient after HCW

Poor reportingPoor reporting

Surgeons do not report up to 70% of Surgeons do not report up to 70% of injuriesinjuries– inconvenient to follow-up after a caseinconvenient to follow-up after a case– not willing to stop a casenot willing to stop a case– assume exposure is “low-risk”assume exposure is “low-risk”– do not want to have serostatus knowndo not want to have serostatus known

Rarely participate in post-exposure Rarely participate in post-exposure strategiesstrategies

Exposure in ORExposure in OR

Types of proceduresTypes of procedures

– High blood volumeHigh blood volume

– Poor visibilityPoor visibility

– Length of timeLength of time

Bloodborne Infections in Bloodborne Infections in Developing Countries (DC’s)Developing Countries (DC’s)

Concerning given global epidemicsConcerning given global epidemicsLack of dataLack of data70% of global HIV cases are in Sub-70% of global HIV cases are in Sub-Saharan AfricaSaharan Africa– But only 4% of worldwide cases of But only 4% of worldwide cases of

occupational HIV infection from this regionoccupational HIV infection from this region

4% of global HIV cases are in North 4% of global HIV cases are in North America/EuropeAmerica/Europe– But 90% of worldwide cases of occupational But 90% of worldwide cases of occupational

HIV infection are reported from this regionHIV infection are reported from this region

Needlestick Injuries in DC’sNeedlestick Injuries in DC’s

90% global surgical need in DC’s90% global surgical need in DC’s

WHO: 90% of needlestick injuries in DC’sWHO: 90% of needlestick injuries in DC’s

35 million HCW’s globally35 million HCW’s globally– 3 million get a NSI each year3 million get a NSI each year– 40% of HCV/HBV in HCW is from 40% of HCV/HBV in HCW is from

occupational exposureoccupational exposure– 2.5% of HIV2.5% of HIV

Risk factors for injuries in DC’sRisk factors for injuries in DC’sPrevalence of infectionsPrevalence of infections– > 20 bloodborne pathogens (malaria/herpes/syphilis)> 20 bloodborne pathogens (malaria/herpes/syphilis)

Vaccine availabilityVaccine availability

Low health expenditure and lack of devicesLow health expenditure and lack of devices

High ratio of patients per HCWHigh ratio of patients per HCW

High Demand for injectionsHigh Demand for injections– 95% injections are therapeutic (not for vaccination)95% injections are therapeutic (not for vaccination)– 80-90% pts visiting clinics in Ghana received an 80-90% pts visiting clinics in Ghana received an

injectioninjection

Developing Countries (ctd.)Developing Countries (ctd.)Uganda: HIV prevalence in MulagoUganda: HIV prevalence in Mulago– Medical Wards 60%; Surgical 30%Medical Wards 60%; Surgical 30%

2004 Mulago survey (nurses/midwives)2004 Mulago survey (nurses/midwives)– 57% stick in last year; 4.18/person/year57% stick in last year; 4.18/person/year– 55% (Mbarara)55% (Mbarara)– In 3 years of trainingIn 3 years of training

6/1000 clinicians would acquire HIV6/1000 clinicians would acquire HIV

10/1000 would acquire Hepatitis B10/1000 would acquire Hepatitis B

Effect on the health workforceEffect on the health workforceAss. Surgeons East Africa (ASEA) SurveyAss. Surgeons East Africa (ASEA) Survey– Deterrent to career choice in surgeryDeterrent to career choice in surgery

Further exacerbates the shortage in health Further exacerbates the shortage in health care workers with direct patient contactcare workers with direct patient contact– AttritionAttrition– Alternative career choice Alternative career choice – Migration and brain drainMigration and brain drain

We have the potential to share effective We have the potential to share effective technologies with our partnerstechnologies with our partners– UCSF and ACSUCSF and ACS

Epi ConclusionsEpi Conclusions

Suture needles cause the majority of Suture needles cause the majority of injuries in the ORinjuries in the OR

The OR lags far behind in preventionThe OR lags far behind in prevention

As surgeons we underreport injuriesAs surgeons we underreport injuries

Risks to patientsRisks to patients

Risks to other members in ORRisks to other members in OR

Major problem for health care workers in Major problem for health care workers in the developing worldthe developing world

ThanksThanks

Fellow contributorsFellow contributors

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