OCCUPATIONAL EXPOSURE TO HUMAN IMMUNODEFICIENCY VIRUS IN PEDIATRICIANS: A PREVIOUSLY UNDESCRIBED HIGH RISK GROUP

Abstract

The risk of occupational HIV exposure in doctors caring for children with HIV infection is unknown. We conducted a retrospective survey among doctors at the Tygerberg Children’s Hospital during September 2001, documenting occupational exposure in the previous 2 years. The overall incidence of needle stick injuries was 62%, but it increased to 91% in junior doctors. More than 50% of junior doctors recorded occupational HIV exposure. The areas of highest risk were the pediatric and neonatal intensive care units. All doctors received postexposure prophylaxis. The risk of occupational exposure to HIV among pediatric health professionals has never been documented. Obstetric residents have previously been identified as a very high risk group. 1 In the United Kingdom, as in other developed countries, where the prevalence of HIV is low and where comprehensive programs are in place to prevent vertical transmission, pediatricians are a low risk group. 2 In South Africa the seroprevalence in women attending public antenatal clinics is 23%. 3 Although a nevirapine-based vertical transmission prevention program has since been introduced, large numbers of HIV-infected children are hospitalized. High plasma HIV RNA concentrations in infected infants may increase transmission risk in health care workers. 4, 5 Objective. Our main objective was to determine the incidence of needle stick injuries and risk of occupational exposure to HIV in doctors working at Tygerberg Children’s Hospital. Background information. Tygerberg Children’s Hospital is a 250-bed tertiary training hospital in the Western Cape Province of South Africa. Medical staff includes specialist pediatricians, specialists in training (residents), medical officers, community service doctors (1 year postinternship) and interns. Methods. We conducted a retrospective survey during September 2001, using a standardized questionnaire requesting information on occupational exposure in the preceding 2 years. All medical staff employed at that time was included. The survey had been precipitated by a spate of needle stick injuries. The study was conducted with permission of the Management Committee of Tygerberg Academic Hospital. Results. All 54 doctors completed the questionnaire. The overall incidence of needle stick injuries was 62% but increased to 91% in junior doctors (Table 1). Four people recorded more than 1 injury.TABLE 1: Overall and HIV-specific occupational exposure in pediatric doctorsA wide variety of incidents were described. Hollow bore needle injury was the most common (85%). Cleaning up after insertion of an iv catheter was the most frequently reported mode of injury (70%). Most incidents occurred outside normal working hours, when the time-adjusted relative risk was increased 4-fold. The majority of incidents occurred in the neonatal wards (24%) and intensive care units (28%). Cardiopulmonary resuscitation was associated with the highest risk in any area. All 14 doctors exposed to HIV used prophylaxis, the majority within 3 h and all within 12 h of the incident. One doctor was exposed twice. Zidovudine and lamivudine were provided. In addition in the 6 months before conducting the survey, 5 purchased a protease inhibitor, indinavir. Side effects were frequent (Table 2). Sixty-four percent said that the side effects significantly influenced their quality of life and work. However, everyone reported completing the 4-week course of prophylaxis.TABLE 2: Adverse effects experienced with HIV prophylaxisDiscussion. There have been few surveys of occupational exposure to HIV in doctors. Studies of needle stick injuries mainly involved medical students 6, 7 and did not address actual HIV exposure. In our study the overall incidence of needle stick injuries was high, but of special concern was that 57% of junior doctors reported occupational HIV exposure. This is similar to the highest levels ever recorded and in a group not previously thought to be at high risk. Residents, who perform most of the difficult procedures, and other junior personnel, who are probably less skilled, are at highest risk. Predictably the time of highest risk is when the physician is either on or post call. The majority of incidents happened while “cleaning up” after inserting an iv catheter. A similar increased risk was found in a dental teaching environment. 8 By having “sharps” containers immediately at hand or using new self-resheathing needles, risk can be reduced. 9 That respondents personally funded a protease inhibitor reflects a high level of anxiety that might have contributed to the good adherence reported. 10 Adverse events were common, although difficult to distinguish from the psychologic impact of the incident.