Thursday, April 21, 2011

HCV/HIV; The Risk Is Low For Edmonton surgical patients

Yesterday the Vancover Sun reported a healthcare worker in Edmonton who tested positive for HIV and Hep C resulted in 200 surgical patients in the region to be tested for HIV and hepatitis C.

How serious is the risk for the transmission of  bloodborne pathogens  from a "healthcare worker to a patient"?

Unless the healthcare worker had deliberately put patients at risk, the risk is low. Higher actually with HBV then HIV, or HCV.

Previously because of reused syringes there have been bloodborne pathogens transmitted to patients via an infected healthcare worker. In the Edmonton article this scenario wasn't mentioned in connection with this particular employee.  The article did note;

In November 2010, more than 170 patients from the Hinton area were contacted and tested for HIV and hepatitis after a health-care worker reused syringes that may have contaminated medication.
A similar situation happened two years earlier, when 2,700 dental and endoscopy patients from High Prairie had to be tested for blood-borne pathogens because of syringe reuse, which is a violation of Alberta’s health standards policies.

In the US the transmission of HCV resulted when reused syringes were used,. view the information here.

In a few of these clinical settings innocent patients were infected with HCV via contaminated syringes, with the drug Fentanyl named at three different clinics; Mayo, Rose Medical Center and Riverside Regional. Apparently in all three cases the guilty parties stole syringes and injected themselves with the painkiller fentanyl replacing the syringes with saline to be reused on patients. We can only surmise how often this has played out across the country in other hospitals or clinics. All three guilty parties were infected with HCV, although not all admitted to knowing it.

According to Academy of Orthopaedic Surgeons the risk for transmission from infected healthcare professional to patient is low.
Preventing the Transmission of Bloodborne Pathogens
This Information Statement was developed as an educational tool based on the opinion of the authors. It is not a product of a systematic review. Readers are encouraged to consider the information presented and reach their own conclusions.
This report provides an overview of strategies intended to reduce the risk of transmitting bloodborne pathogens in a variety of orthopaedic settings. It includes information on preventing the transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV), and discusses issues involving infected health care personnel (HCPs). Numerous documents from the United States Centers for Disease Control and Prevention (CDC) as well as other scientific publications were reviewed to arrive at this summary of recommendations for the implementation and monitoring of strategies most relevant to the orthopaedic surgeon.
HCP-to-patient transmission of bloodborne pathogens
Transmission of HBV, HCV, and HIV from HCP to patient has been documented.7, 36-46 However, the risk of transmission from HCP to patient is much lower than from patient to HCP. The vast majority of HCPs infected with a bloodborne virus do not pose a risk to patients, because they do not perform activities where the conditions necessary for transmission are met. Three conditions are necessary for HCPs to pose a risk for transmitting a bloodborne virus to patients. First, the HCP must be viremic (i.e., have infectious virus circulating in the bloodstream). Second, the HCP must be injured or have a condition (e.g. weeping dermatitis) that allows direct exposure to his/her blood or other infectious body fluids. Third, the HCP’s blood or infectious body fluid must gain direct access to a patient’s wound, traumatized tissue, mucous membranes, or similar portal of entry. The greatest risk of transmission of infection from HCP to patient is for HBV. HCP-to-patient transmission of HBV has primarily occurred during invasive procedures performed by HBeAg-positive HCPs.36-38,40,41 Nonetheless, transmission of HBV from an infected provider to patient(s) has been documented for HCPs who have a mutant form of HBV that prevents expression of e antigen and generally have lower levels of viremia than those who are e antigen positive.42 In the UK, HCPs who have this pre-core mutant are prohibited from performing invasive procedures.43 There is a lack of consensus in the US about similar restrictions.
Of the three bloodborne viruses, HIV carries a lowest risk of transmission from HCP to patient. Worldwide, there are only four reported instances of HIV transmission occurring from an infected HCP to a patient.47,46,48,49 A cluster of six patients was infected by a dentist in Florida.45 In 1997, an orthopaedic surgeon in France transmitted HIV to one of his patients during an invasive procedure.46 A third case, where transmission is suspected, concerns an instance of HIV transmission from an infected nurse to a surgical patient in France.48 Although there is no published explanation of the mode of transmission, HIV sequencing implicated the nurse as the source for the patient’s infection. A fourth case involved transmission from an HIV-infected infected obstetrician to his patient during performance of caesarean delivery.49 This low number of cases of HIV transmission from an HIV-infected HCP to patient indicates an extremely low risk of transmission through this mechanis


Should HCV-infected persons be restricted from working in certain occupations or settings?

CDC's recommendations for prevention and control of HCV infection specify that persons should not be excluded from work, school, play, child care, or other settings on the basis of their HCV infection status. There is no evidence of HCV transmission from food handlers, teachers, or other service providers in the absence of blood-to-blood contact.

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