Literature Reviews
Montecalvo MA, Lee MS, DePalma H, et al. Seroprevalence of human immunodeficiency virus-1, hepatitis B virus, and hepatitis C virus in patients having major surgery. Infect Control Hosp Epidemiol 1995; 16:627-632.
In this study of patients having major surgery at a single medical center, researchers found that of 1,062 operations evaluated, 71 were performed on patients with either anti-HIV, HBsAg, or anti-HCV. The prevalences of serologic evidence of at least one of the three viruses are high in patients aged 25 to 44 years.
Anti-HCV is more prevalent than anti-HIV or HBsAg and is predictive of anti-HIV seropositivity. The authors point out that testing for anti-HIV alone would have detected only 24% of patients infected with a bloodborne pathogen.
"These data strongly underscore the importance of universal precautions, the need to develop strategies and techniques to reduce blood exposure, and the importance of the reporting and follow-up of percutaneous injuries," they state.
Awareness of infection rates for surgical patients is essential to assess the risk for surgeons and operating room personnel to acquire HIV, HBV, or HCV. Therefore, a seroprevalence study was undertaken at Westchester County Medical Center in Valhalla, NY, a 654-bed tertiary care teaching hospital. The hospital is a designated AIDS treatment center.
During a 16-week period in 1992, sera were obtained from patients having major surgery by collecting surplus from specimens sent for transfusion blood typing and screening or cross-matching. Samples were tested blindly for HIV antibody, HBV core antibody, HBV surface antigen, and HCV antibody. Demographic characteristics and operation category were correlated with serologic results by univariate and regression analyses. Demographic data and surgical procedures were available for 1,056 operations performed on 1,004 patients.
Median age of patients was 55 years (range, 1 to 96), and 570 (54%) were male. Of the operations, 263 (25%) were cardiothoracic, 215 (20%) general surgery, 120 (11%) vascular or transplant, 116 (11%) orthopedic, 93 (9%) obstetric or gynecologic, 73 (7%) urologic, 70 (7%) neurosurgical, 52 (5%) plastics or burn, 24 (2%) otolaryngologic, and 5 (0.5%) ophthalmologic. Twenty-five other operations included 22 angioplasties, two bronchoscopies, and one cerebral angiogram.
Of the 71 operations performed on patients with at least one of the viruses (6.7%), anti-HIV was present for 17 (1.6%). There were 136 operations (12.8%) performed on patients with anti-HBc, but HBsAg was detected for only 15 (1.4%). Anti-HCV was present in 55 operations (5.2%).
Seroprevalence rates were highest for operations performed on the 269 patients (25.4%) aged 25 to 44. At least one virus was present in 45 operations (16.7%): anti-HIV in 15 (5.6%), HBsAg in six (2.2%), and anti-HCV in 39 (14.5%).
The likelihood of having antibody to at least one virus differed significantly by age, with 25.4% positive in persons from 25 to 44 years old, compared to 2% to 3.7% of procedures involving other age groups.
Anti-HCV was present significantly more often than anti-HIV (5.2% vs. 1.6%) or HBsAg (5.2% vs. 1.4%). If sera had been tested for anti-HIV only, only 17 (24%) of the 71 operations performed on patients infected with at least one bloodborne viral pathogen would have been detected. Of the 17 operations performed on HIV-infected patients, coinfection with HCV was common.
The likelihood of having antibody to any one virus differed significantly by operation category, with 11 (11.8%) of 93 obstetrics and gynecology operations positive, compared to 2.7% to 8.8% of other types of operations.
The high rate of anti-HCV in surgical patients points to the need for prospective studies to define the risk to health care workers of acquiring the virus through needlestick injuries, the authors note. *
Wurtz R. Infection control in public hospitals. Infect Control Hosp Epidemiol 1995; 16:642-646.
Public hospitals' infection control problems differ from those in other hospitals due to paucity of resources and a high number of indigent patients. Infection control efforts among public hospital employees also present a unique set of problems.
"Employees of public hospitals are exposed to a wide range of occupational hazards, from scabies to HIV and multidrug-resistant TB," the author states. Difficult, even dangerous, working conditions can cause employee morale to suffer.
While protective gear and needle safety devices are needed for workers who care for numerous patients with identified and unidentified airborne and bloodborne infections, public hospitals can least afford those products.
Health care workers in public hospitals care for many intravenous drug users who may be infected with hepatitis B, hepatitis C, and HIV. Thus, the workers are at risk for occupational exposure to those viruses. The author, a practitioner at Cook County Hospital in Chicago, emphasizes that HBV vaccination programs should be especially active. She also reminds that immunoglobulin does not prevent against HCV following parenteral exposure, and the efficacy of zidovudine prophylaxis following exposure to HIV is unknown.
Public hospitals rely heavily on house staff, who may not be knowledgeable about infection control issues. Residents may violate basic infection control practices and not report communicable disease conditions to the infection control department. House staff should be educated at conferences, morning reports, grand rounds, and through newsletters and paycheck inserts, as well as with pocket cards that summarize infection control principles and reportable diseases.
Because employees represent the community, public hospital workers may have higher baseline rates of tuberculin skin-test positivity and may be more likely to have community-acquired conversions than employees of other hospitals. To establish the baseline community rate of skin-test positivity, test conversions of employees who care for patients should be compared to test conversions of those who do not.
In addition, employees may not be immune to measles, rubella, and varicella because they may not have been exposed or vaccinated in childhood. Infection control and employee health programs should document whether new employees are tuberculin skin-test positive and whether they are immune to HBV, measles, rubella, and varicella.
Employee unions, common in public hospitals, are concerned about protecting their members from occupational exposure to infectious diseases. Union leaders can serve as allies, helping to promote vaccination programs, evaluate protective gear, and educate HCWs.
Understaffing can cause employees to have little time to go to the employee health service for screenings. Union rules may prevent hospitals from using disciplinary measures such as withholding paychecks for noncompliance. The author suggests instituting a roving employee health service team to go to worksites to perform TB skin tests, obtain baseline and follow-up serology, and administer hepatitis and influenza vaccine.
Infection control programs in public hospitals also must use creative strategies to teach employees infection control principles, especially if a large proportion of employees are functionally illiterate in English. Comic-book style materials, cassette tapes, and videotapes in various languages can convey information to employees on all shifts.
The special problems that abound in public hospitals need not be obstacles to an effective infection control program, the author concludes. Instead, practitioners can design creative, cost-effective programs that turn a hospital's weaknesses into strengths. *
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