Review of management of incidents involving exposure to blood in a London teaching hospital, 1989-91.

OBJECTIVE--To review management of incidents involving exposure to blood reported to an occupational health unit. DESIGN--Analysis of all reported incidents from January 1989 to June 1991. SETTING--London teaching hospital. SUBJECTS--447 health care workers and students. MAIN OUTCOME MEASURES--Immunisation against hepatitis B virus before exposure, proportion of known source patients tested for hepatitis B surface antigen and HIV antibodies, and reasons for not testing known source patients. RESULTS--447 incidents were reported: 337 sharps injuries and 110 other exposures. 310 staff reporting incidents (205 (82%) nurses) were already immune to hepatitis B virus, nearly always because of immunisation. 345 source patients were identified, 77 of whom had already been tested for hepatitis B surface antigen (28 positive results) and 58 for HIV antibodies (18 positive results). Of those not previously tested, 145 of 266 were subsequently tested for hepatitis B surface antigen (two positive) and 149 of 287 for HIV antibodies (none positive). The main reasons for not testing source patients were that the incident was not considered a risk, that the patient had gone home, and that the clinical team were unwilling to ask the patient. Specific hepatitis B immunoglobulin was given to 18 staff who were not immune and was avoided in 11 cases by a negative result for the patient. Prophylactic zidovudine was discussed but not given to any staff member. CONCLUSIONS--Management of exposure to blood is improved by widespread immunisation against hepatitis B virus and by knowledge of source patients'' hepatitis B virus and HIV status.     

Hepatitis B in a hospital for the mentally subnormal in southern England.

The prevalence of hepatitis B viral (HBV) infection was assessed in 340 patients and 268 staff in a hospital for the mentally subnormal in Wessex. Hepatitis B surface antigen (HBsAg), antibody to hepatitis B core antigen, antibody to HBsAg, e antigen (eAg), and antibody to eAg were used as markers of such infection. Forty patients and 10 staff had evidence of recent or current infection, while 149 patients and 50 staff had evidence of past infection. HBV markers were more common in mongols, epileptics, patients with cerebral palsy, and those of lower mental grades and reached a peak after 5-15 years of hospitalisation. eAg was detected in 12 out of 26 patients with HBsAg but in none of the four staff with HBsAg. Abnormal liver function values were found in 24 (60%) of the patients with recent or current HBV infection but in only 30 (19%) of those without HBV markers. Among the staff the prevalence of HBV markers correlated with the duration of employment and degree of contact with patients. Of those with recent or current infection, 4 (40%) had abnormal liver function values compared with 25 (12%) of those without HBV markers. Despite the high prevalence of markers clinically overt hepatitis B was rare.     

Prevalence of HBsAg and anti HBs in hospital personnel

Of the 473 employees of a Prague hospital, examined for the presence of hepatitis B surface antigen (HBsAg) and the antibody to it (anti HBs), 23 (4.9%) were shown to have the antigen and 88 (18.6%) to have the antibody. No differences were found in the prevalence of HBsAg and anti HB according to sex and age, but the percentage of persons with antibodies increased with increasing length of occupation. Significantly higher levels of antibodies were found in persons having direct contact with the patients or their excretions (nurses, laboratory assistants). Positive serological findings were more frequent in employees with a history of falling ill with hepatitis after entering employment in the health services than in persons without this history. In the serological evidence of hepatitis B according to work place, those working in biochemical and haematological laboratories and in the blood transfusion department took first place, followed by persons employed in medical and surgical departments.     

Hepatitis B virus infection in dental surgical practice.

Sixty-one dental surgeons at King''s College Hospital were interviewed to establish the incidence of attacks of viral hepatitis and to relate this to environmental risk factors. Six (10%) had a history of hepatitis, in one case due to infection with the hepatitis B virus. Screening blood for HBsAg by radioimmunoassay showed no carriers of the antigen, but transient antigenaemia was observed in one dentist. Antibody to HBsAg, tested by radioimmunoassay, was detected in four dentists (7%), only one of whom had had clinical hepatitis. Dental surgeons may be more at risk from infection with the hepatitis B virus than the general population, although this should be minimised in hospital practice, where the most infected patients will already have been identified and appropriate precautions can be taken. The risk of transmission from an antigen-positive dentist to his patients is probably much smaller, and there is no evidence to restrict his clinical activities.     

Hepatitis B virus infection in medical and health care personnel.

Analysis of 51 cases of hepatitis B virus infection in health care workers admitted as patients to the liver unit over seven years showed three healthy carriers of hepatitis B virus, seven cases of fulminant hepatic persistent hepatitis, 17 cases of chronic active hepatitis (of whom 11 had cirrhosis), and five cases of hepatocellular carcinoma. To date 11 of these patients have died. Only 15 of the 51 patients had a history of direct occupational exposure and only three patients could recall specific inoculation injuries. In contrast, the source of infection was apparent in 32 of 50 consecutive cases of fulminant hepatic failure or acute hepatitis B in nonmedical staff. Since specific inoculation injuries are not the usual mode of infection ion medical staff and since only a few of the patients who are hepatitis B virus carriers will be detected by selective screening of "high-risk" patients, the overall risk of infection can be reduced only by stricter precautions in the handling of any patient''s blood and by the use of hepatitis B virus vaccines for medical staff at high risk.     

Is Universal HBV Vaccination of Healthcare Workers a Relevant Strategy in Developing Endemic Countries? The Case of a University Hospital in Niger

Background

Exposure to hepatitis B virus (HBV) remains a serious risk to healthcare workers (HCWs) in endemic developing countries owing to the strong prevalence of HBV in the general and hospital populations, and to the high rate of occupational blood exposure. Routine HBV vaccination programs targeted to high-risk groups and especially to HCWs are generally considered as a key element of prevention strategies. However, the high rate of natural immunization among adults in such countries where most infections occur perinatally or during early childhood must be taken into account.

Methodology/Principal Findings

We conducted a cross sectional study in 207 personnel of 4 occupational groups (medical, paramedical, cleaning staff, and administrative) in Niamey’s National Hospital, Niger, in order to assess the prevalence of HBV markers, to evaluate susceptibility to HBV infection, and to identify personnel who might benefit from vaccination. The proportion of those who declared a history of occupational blood exposure ranged from 18.9% in the administrative staff to 46.9% in paramedical staff. Only 7.2% had a history of vaccination against HBV with at least 3 injections. Ninety two percent were anti-HBc positive. When we focused on170 HCWs, only 12 (7.1%) showed no biological HBV contact. Twenty six were HBsAg positive (15,3%; 95% confidence interval: 9.9%–20.7%) of whom 8 (32%) had a viral load >2000 IU/ml.

Conclusions/Significance

The very small proportion of HCWs susceptible to HBV infection in our study and other studies suggests that in a global approach to prevent occupational infection by bloodborne pathogens, a universal hepatitis B vaccination of HCWs is not priority in these settings. The greatest impact on the risk will most likely be achieved by focusing efforts on primary prevention strategies to reduce occupational blood exposure. HBV screening in HCWs and treatment of those with chronic HBV infection should be however considered.     

Acute hepatitis B in patients in Britain related to previous operations and dental treatment.

The frequency of transmission of hepatitis B virus infection from health service staff to patients was assessed from reports of confirmed cases of acute clinical hepatitis in 1980-3. During the four years 4505 reports (91% of the total) included replies to a question about recent operations; 153 patients (3.4%) had this history. Transfused blood or blood products were considered the source for 27 cases (0.06%). Eleven patients (0.02%) were infected in two clusters, both in cardiac surgery units; six were caused by a perfusion technician, who was a symptomless carrier, and five by a surgical registrar during the incubation period of an acute hepatitis B infection. The estimated average annual risk of a patient developing acute hepatitis B as part of a cluster caused by staff during surgical procedures was one in a million operations. For another 11 patients blood transfusion could not be excluded as a source. Where no association between surgery and hepatitis was found the incidence of a history, lay between 2.3 and 2.6%. The Hospital In-Patient Enquiry data showed that about 2.4% of the population had had operations in a six month period. These findings suggest that transmission of hepatitis B infection from staff to patients is rare in Britain and that the small risk could be eliminated by attention to measures to preserve asepsis and by immunising staff at risk.     

Survey of "do not resuscitate" orders in a district general hospital.

OBJECTIVE--To evaluate the local use of written "Do not resuscitate" orders to designate inpatients unsuitable for cardiopulmonary resuscitation in the event of cardiac arrest. DESIGN--Point prevalence questionnaire survey of inpatients'' medical and nursing records. SETTING--10 acute medical and six acute surgical wards of a district general hospital. PARTICIPANTS--Questionnaires were filled in anonymously by nurses and doctors working on the wards surveyed. MAIN OUTCOME MEASURES--Responses to questionnaire items concerning details about each patient, written orders not to resuscitate in the medical case notes and nursing records, whether prognosis had been discussed with patients'' relatives, whether a "crash call" was perceived as appropriate for each patient, and whether the "crash team" would be called in the event of arrest. RESULTS--Information was obtained on 297 (93.7%) of 317 eligible patients. Prognosis had been discussed with the relatives of 32 of 88 patients perceived by doctors as unsuitable for resuscitation. Of these 88 patients, 24 had orders not to resuscitate in their medical notes, and only eight of these had similar orders in their nursing notes. CONCLUSIONS--In the absence of guidelines on decisions about resuscitation, orders not to resuscitate are rarely included in the notes of patients for whom cardiopulmonary resuscitation is thought to be inappropriate. Elective decisions not to resuscitate are not effectively communicated to nurses. There should be more discussion of patients'' suitability for resuscitation between doctors, nurses, patients, and patients'' relatives. Suitability for resuscitation should be reviewed on every consultant ward round.     

Understanding of elderly patients' resuscitation preferences by physicians and nurses.

We compared the understanding by family physicians and nurses of their elderly outpatients'' preferences for cardiopulmonary resuscitation and mechanical ventilation under 3 scenarios reflecting varying qualities of life. Physicians and nurses correctly predicted patients'' treatment preferences in from 59% to 84% and 53% to 78% of cases, respectively, for the various decisions. For most decisions, neither physicians nor nurses were significantly more accurate in their predictions than expected by chance alone. Moreover, nurses and physicians did not significantly agree with one another in their predictions of patients'' preferences for any of these decisions. These results suggest that while nurses'' and physicians'' perceptions of patients'' preferences for life-sustaining treatment are not necessarily similar, neither nurses nor physicians systematically understand their elderly patients'' resuscitation preferences.     

Hepatitis B surface antigen (HBsAg) infection in a hemodialysis unit. II. Factors affecting host immune response to HBsAg.

Serum from 86 hemodialysis patients, 105 healthy hospital staff "at risk" and 160 regular hospital staff was screened for hepatitis B surface antigen (HBsAg) and antibody (anti-HBs). The combined prevalence of HBsAg and anti-HBs was higher in the staff of the artificial kidney unit (57.7%) than in the hemodialysis patients (33.7%). The healthy subjects with HBsAg infection responded significantly more often by producing anti-HBs compared with the hemodialysis patients. Twelve of 29 (41.4%) hemodialysis patients with HBsAg infection produced anti-HBs, while 17 (58.6%) remained positive for HBsAg. This differential response could not be attributed to age, sex, time spent undergoing hemodialysis, delayed cutaneous reactivity or response to phytohemagglutinin (PHA) or pokeweed mitogen (PWM). However, a much larger proportion of patients with HBsAg than with anti-HBs had previously received blood transfusions (88.2% v. 33.3%). Our results indicate that development of the chronic HBsAg carrier state or production of anti-HBs in uremic patients may be influenced by the route of immunization or the dose of antigen, or both. Although uremic patients maintain normal in vitro response to PHA and PWM, they may have depressed immunity in vivo because of a decreased total number of T-lymphocytes.     

Occult hepatitis B virus infection among injecting drug users in the Central-West Region of Brazil

The prevalence of occult hepatitis B virus (HBV) infection was investigated in 149 hepatitis B surface antigen (HBsAg) negative injecting drug users (IDUs) in the Central-West Region of Brazil. Of these individuals, 19 were positive for HBV DNA, resulting in an occult HBV infection prevalence of 12.7% (19/149); six of these 19 individuals had anti-HBV core and/or anti-HBV surface antibodies and 13 were negative for HBV markers. All IDUs with occult hepatitis B reported sexual and/or parenteral risk behaviours. All HBV DNA-positive samples were successfully genotyped. Genotype D was the most common (17/19), followed by genotype A (2/19). These findings reveal a high prevalence of occult HBV infection and the predominance of genotype D among IDUs in Brazil''s Central-West Region.     

Study of smoking habits in hospital and attitudes of medical staff towards smoking.

Most hospital policies place little or no restriction on patients'' smoking in hospital. In this study patients were surveyed to determine if they smoked and if their doctors advised or ordered them to stop smoking in hospital. As well, the smoking habits and attitudes towards smoking of the medical staff and other hospital workers were explored. Of 741 patients 37% were smokers, and those who responded fully to a questionnaire 86% continued to smoke in hospital. Patients who were advised or ordered not to smoke (59%) were no more likely to stop smoking than those who were not so advised or ordered. Physicians were less likely to smoke than other hospital staff, and those who did smoke were much more likely not to smoke while in the hospital. Physicians appear to have a reasonable appreciation of the health hazards of smoking, and almost two thirds are in favour of stricter restrictions on patients'' smoking in hospital. The ineffectiveness of their efforts is primarily due to hospital policies that are not in keeping with physicians'' standards of practice and with established knowledge of the deleterious effects of smoking on health.     

Prevalence and Risk Factors for Latent Tuberculosis Infection among Health Care Workers in China: A Cross-Sectional Study

Background

Health care workers (HCWs) are at risk of latent tuberculosis infection (LTBI). In China, tuberculosis (TB) is a major public health problem, but the prevalence of LTBI in HCWs especially in the hospital for pulmonary diseases has not been assessed enough. The aim of this study was to determine the prevalence and putative risk factors of LTBI among HCWs in a chest hospital and a TB research institute in China.

Methodology/Principal Findings

A cross-sectional study was conducted among HCWs in China in 2012. LTBI was assessed by T-SPOT.TB, and information on HCWs was collected using a standardised questionnaire. Risk factors for LTBI were analyzed by univariate and multivariate regression. The overall prevalence of LTBI among HCWs was 33.6%. Analyzed by job category, the highest prevalence was found among laboratory staff (43.4%). In the different workplaces, the proportion of LTBI was significantly higher among the high risk workplaces (37.4%) compared to the low risk workplaces. The duration of employment had a significant impact on the prevalence of LTBI. Positive T-SPOT.TB test results accounted for 17.6%, 16.8%, 23.5%, 41.8% and 41.6% in groups of ≤2, 3–5, 6–10, 11–20, and >20 working years respectively. In multivariate analysis, job categories (Laboratory staff [2.76 (95% CI: 1.36; 5.60)], technician staff [2.02 (95% CI: 1.12; 3.64)]); working duration as a HCW for 11 to 20 years [3.57 (95% CI: 1.46; 8.71)], and 20 years above [3.41 (95% CI: 1.28; 9.11)]; and the history of household TB contact [2.47 (95% CI: 1.15; 5.33)] were associated with increased risk of LTBI.

Conclusions/Significance

Prevalence of LTBI estimated by T-SPOT.TB is high among Chinese HCWs and working duration, job category and the history of household TB contact were associated with increased risk. These data highlight adequate infection control measures should be undertaken.     

Editor's preface

OBJECTIVE: To describe the process used to notify pediatric patients who received transfusions of blood or blood products at our institution before donor blood was routinely screened for antibodies to HIV (1985) and hepatitis C virus (1990), and to evaluate the effectiveness of the notification program. DESIGN: Patients who had received transfusions were identified through the hospital''s medical records and the records from the Transfusion Medicine Laboratory. Patients were contacted by registered mail to provide notification of transfusion. A questionnaire was included with the notification to obtain information about the patient''s awareness of the transfusion and whether he or she had undergone or planned to undergo testing for HIV and hepatitis C virus. SETTING: Tertiary care university-affiliated teaching hospital in Hamilton, Ont. PATIENTS: Patients 16 years of age or younger who had received blood products between February 1978 and November 1985. Patients who had received only albumin or immune serum globulin were not included as these products were not associated with viral transmission in Canada. RESULTS: Notification letters were sent to 1546 patients. Of these letters 522 (33.8%) were returned undelivered. Of the 1024 patients contacted 493 (48.1%) responded to the questionnaire, of whom 157 (31.8%) were not aware of their transfusion. A total of 130 (26.4%) of the respondents had already undergone testing for HIV, and 342 (69.4%) indicated that they would undergo such testing as a result of the notification. In contrast, only 30 (6.3%) of 474 respondents had undergone testing for hepatitis C virus, but 425 (89.7%) indicated that they would undergo such testing. Overall, the patients'' response to the notification was neutral or positive; however, a number of patients expressed dissatisfaction and anxiety. CONCLUSIONS: The high proportion of patients who were unaware that they had undergone transfusion and who decided to undergo testing for HIV and hepatitis C virus as a result of notification supports the use of notification programs such as this one.     

Prevalence of viral hepatitis among the hospital staff in CSR between 1980 and 1982

The hepatitis morbidity data were used to study prevalence rate of manifest viral hepatitis among the hospital staff members in CSR over a 3-year period between 1980 and 1982. This study showed that the overall hepatitis morbidity rate was 2.68 per 1,000 health personnel and was 3.6 times as high as that recorded in a normal population matched by age. The mean HBsAg positivity rate was 1.67 per 1,000 and was 5.8 times the rate in the control population group. The rate of HBsAg-negative cases of hepatitis was 1.01 per 1,000 health personnel and was higher than double the rate of morbidity encountered in an age-matched normal population. The highest morbidity rates were recorded in the lower-grade and auxiliary health personnel. When compared with an age-matched normal population the hospital staff members at all departments had distinctly higher morbidity rates than the general population, but the highest risk of acquiring viral hepatitis was evidently run by the personnel at departments of renal dialysis, biochemistry, hematology, infectious diseases, internal medicine, surgery, urology and TRD (tuberculosis and respiratory diseases). Of a total number of recorded cases of viral hepatitis those with HBsAg positivity predominated, especially at departments of urology, TRD, internal medicine, renal dialysis, psychiatry and hematology. Analyzed by specialty and professional status of personnel these viral hepatitis morbidity rates encountered among the hospital staff members seem to point to at least two conclusions: this infection in the health personnel is work-related and its transmission and spread is dependent on the frequency and intensity of contact with the blood and other secretions of infectious patients.     

Success of a program of routine prenatal screening for hepatitis B surface antigen: the first 2 years.

Prenatal screening for hepatitis B surface antigen (HBsAg) restricted to women with defined risk factors for chronic hepatitis B virus (HBV) infection fails to identify many carriers. A centralized program of routine HBsAg screening for all pregnant women in Alberta was introduced in 1985. We collected and analysed data for the first 2 years of the program in Edmonton to determine the frequency of risk factors for HBsAg positivity, the proportion of multiparous HBsAg-positive women not identified in previous pregnancies, the efficiency and cost-effectiveness of providing immunoprophylaxis to infants at risk of HBV infection and the degree of success in inducing adequate protection. A total of 149 women (158 pregnancies) were found to be HBsAg positive. Risk factors were readily ascertainable for 85% of the women; the remaining 15% would not have been identified through risk-selective screening. The most common risk factors were Oriental ethnic origin, history of hepatitis, jaundice or multiple transfusions of blood or blood products, and occupational exposure to blood. Although 86% of the multiparous HBsAg-positive women had risk factors, only 7% had been identified in previous pregnancies. The Alberta program appears to be cost-effective. We conclude that only routine prenatal screening will identify all infants at risk of perinatal HBV infection and that a comprehensive public health program involving central laboratories, private physicians and public health staff can be highly effective and efficient in protecting infants against hepatitis B.     

The Vancouver Lymphadenopathy - AIDS Study: 2. Seroepidemiology of HTLV-III antibody

Testing for antibody to human T-lymphotropic retrovirus (HTLV-III) was carried out in 448 participants in the Vancouver Lymphadenopathy-AIDS (acquired immune deficiency syndrome) Study. The overall prevalence rate of seropositivity was 34%. Of 130 seronegative subjects followed for an average of 8.5 months, 14 became seropositive; thus, the approximate annual seroconversion rate was 15%. More than 100 male sexual partners in one''s lifetime, frequent receptive anal intercourse, fisting, a history of gonorrhea or hepatitis, and frequent sexual contact in clubs were found to be independent risk factors for HTLV-III seropositivity.     

Prevalence of hepatitis E virus antibodies in individuals exposed to swine in Mato Grosso, Brazil

This study was conducted to estimate the prevalence of hepatitis E antibodies (anti-HEV) among individuals exposed to swine in the rural areas of the state of Mato Grosso (MT) in Brazil. The study included 310 participants who had an average age of 39 years. Fifty-one per cent of the participants were female and 26 (8.4%) were anti-HEV-positive. Concomitantly, we studied 101 blood donors from the urban area of the state capital who had never lived in a rural area or handled swine. Four per cent (4%) of these individuals were anti-HEV-positive (p = 0.206). When we compared the anti-HEV-positive participants who had been exposed to swine with the anti-HEV-negative participants, we noticed associations between the presence of anti-HEV and increased age, a history of blood transfusions and contact with other farm animals. However, after a multivariate analysis was performed, this association was not confirmed. Finally, the ratio of anti-HEV-positive individuals who had been exposed to swine in rural MT was similar to that found in previous studies in Brazil. This prevalence did not characterise this type of exposure as a risk factor for HEV infection in this region.     

Community Nurses' View of General Practice Attachment

An analysis of 98 health visitors and district nurses attached and non-attached to general practitioners in three local authority areas showed that most of them were aged over 40 and that many had entered domiciliary work because of the convenient hours or because of its intangible attractions. Adequate preparation for attachment was considered important, particularly a clear definition of the roles of the attached staff and their relationships to other workers in the practice.Attached staff were found to be much more satisfied with the information given by the general practitioner about their patients than were unattached staff, and the former usually had access to the patients'' medical records. The principal advantages of attachment were listed as access to family history; improved co-ordination within the practice and co-operation with the social services; favourable patient response; and increased mileage and work-load; the impossibility of crossing local authority boundaries; and having to deal with families registered with more than one doctor.