Epidemiology of Perioperative Bloodborne Infections UCSF Department of Surgery Grand Rounds March 29, 2006

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

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

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

Hepatitis B 1.25 million people in US w/chronic HBV 5% of acute HBV -> 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

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

Worldwide healthcare worker to patient transmission (Perry et al., forthcoming) 133 reported total cases of transmission –HIV: 2 surgeons-> 3 pts (0.09% pts infected) –HBV: 12-> 91 pts (2.96% pts infected) –HCV: 11-> 39 pts (0.36% pts. infected) HBV: Surgeon->pt transmission –Most commonly when e antigen positive –Many without evidence of injury to hands

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?

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

Surveillance Exposure Prevention Information Network (EPINet) –Dr. Janine Jagger (1991) UVa. –International Health Care Worker Safety Center –>1500 US hospitals; 70 facilities National Surveillance System for Health Care Workers (NaSH) –CDC (1995) –80 facilities in 28 states

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 HCW’s

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)

Exposure Data in OR 33% (Highest proportion) of hospital- based percutaneous injuries (Epinet 2003) –vs pt rooms, ER, clinics 16.5% (2 nd ) for hospital-based non- percutaneous injuries (NaSH) Blood exposure events in 6-50% of surgical procedures (1997) Cuts or needle sticks %

Trends: OR lags in prevention

38% drop in injuries in patient rooms (all devices) only 5.7% drop in OR injuries

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

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

Trends in Needle injuries

33% decline hollow bore needles 27% increase suture needles

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 (<0.05%) are highest risk –ie hollow bore needles Up to 1/3 devices come into contact with patient after HCW

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

Exposure in OR Types of procedures –High blood volume –Poor visibility –Length of time

Bloodborne Infections in Developing Countries (DC’s) 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

Needlestick Injuries in DC’s 90% global surgical need in DC’s WHO: 90% of needlestick injuries in DC’s 35 million HCW’s globally –3 million get a NSI each year –40% of HCV/HBV in HCW is from occupational exposure –2.5% of HIV

Risk factors for injuries in DC’s Prevalence of infections –> 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

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

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

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

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