Transmission Of Blood-borne Viruses Research Articles

Buprenorphine diversion and injection in Melbourne, Australia: an emerging issue?

To examine indicators of buprenorphine diversion and injection among injecting drug users in Melbourne, Australia and to determine the factors associated with buprenorphine injection. Melbourne arm of the 2002 Illicit Drug Reporting System (IDRS) cross-sectional study. Five Needle and Syringe Programme sites in Melbourne, Australia. A total of 156 current injecting drug users (IDU). Study eligibility criteria were at least monthly injection during the previous 6 months, and Melbourne residence for at least the preceding 12 months. Structured questionnaire covering demographic characteristics, drug use history, the price, purity and availability of drugs, criminal activity, risk-taking behaviours, health-related issues and general drug use trends. Over one-third (37%) of the study sample reported injecting buprenorphine in their life-time and 33% reported injecting the drug in the last 6 months. Recent buprenorphine injection was associated with the injection of other drug types (i.e. polydrug injectors), opioid substitution treatment, injection-related health problems and involvement in crime. Almost half (47%) of those who reported recent buprenorphine injection reported obtaining the drug illicitly at least once during that time. Given the significant health harms associated with intravenous buprenorphine use (e.g. vein damage, abscesses and infections, precipitated withdrawal, blood-borne virus transmission, hospitalization and death), routine monitoring of the misuse of buprenorphine in Melbourne is warranted. These results suggest the need for development of effective countermeasures to address diversion and injection of buprenorphine in this setting.

Non-injecting routes of administration among entrants to three treatment modalities for heroin dependence.

A sample of 535 entrants to opioid dependence treatments across three treatment modalities were administered a structured interview to ascertain the prevalence of non-injecting heroin use. Ten per cent of participants had used heroin primarily by smoking/inhaling in the month preceding interview, and 9% had used heroin and other drugs exclusively by non-injecting routes. Non-injectors were younger (25.3 vs. 29.5 years), had higher levels of education (10.6 vs. 10.0 years), were more likely to be employed (33 vs. 18%) and had lower levels of recent crime (31 vs. 56%). They also had shorter heroin using careers (5.1 vs. 9.9 years), fewer symptoms of dependence (5.1 vs. 5.6), had been enrolled in fewer previous treatment episodes (3.3 vs. 11.5) and had less extensive lifetime (8.0 vs. 9.1 drug classes) and recent (3.6 vs. 4.9) polydrug use. Non-injectors were substantially less likely to report lifetime (13% vs. 58%) or recent (2% vs. 29%) heroin overdoses. There were no differences between the general physical and psychological health of the two groups. While non-injectors had a lower level of post-traumatic stress disorder (29% vs. 34%), there were no differences in levels of major depression, attempted suicide, antisocial personality disorder, or borderline personality disorder. A substantial minority of Australian treatment entrants are now using heroin exclusively by non-injecting routes. While this group is younger, and has substantially reduced risk of overdose and blood borne virus transmission, the physical and psychological health of non-injectors mirrors that of injectors.

Heterosexual relationships among heroin users in Italy

This study investigated how many stable partners of drug users (DUs) had a history of drug use or were current DUs. Of 589 DUs interviewed, 41% reported that they had a partner with current or previous experience of drug addiction. A strong gender difference emerged: 77% of female DUs reported a stable relationship with partners with a history of addiction, versus only 30% for male DUs. Partners with a history of drug dependence are more likely to be: male, older, with a lower educational level and a lower rate of stable employment than partners without a history of drug addiction. Logistic regression analysis indicated that the characteristics of heroin users who have current partners with histories of drug use include: female gender, older age, living with a partner, lengthy duration of the relationship and HIV positive status. Fewer subjects are married if the partner has a history of addiction, and there is an association between lengthy drug use and partner without drug addiction history. The high percentage (59%) of subjects who were in stable relationships with partners without histories of heroin addiction and the relatively long duration of these relationships, raises the issue of possible transmission of blood-borne viruses from the DUs to their sexual partners. The study does suggest the need for consideration of sexual partnerships and gender differences in providing drug abuse treatment for heroin users.

14 Pediatric Community-Acquired Needlestick Injuries: Description and Risk of Seroconversion

Community-acquired needlestick injuries (CA-NSI) are an emerging phenomenon. Although anxiety exists concerning the perceived risk of transmission of blood-borne viruses, seroconversion in this setting appears to be a rare event. To describe the circumstances surrounding pediatric CA-NSI and to document the rate of seroconversion of HIV, HBV and HCV in these children. We conducted a retrospective chart review of a cohort of children presenting with a CA-NSI to the Emergency Department of the Montreal Children's Hospital between January 1, 1988 and October 30, 2003. Patients were identified by review of the Infectious Disease Clinic records. The variables collected included demographics (date of birth, sex, postal code), circumstances of injury, prophylaxis offered (HIV, HBV), vaccination status and follow-up serology at 6 months post-injury. Data were analyzed using descriptive statistics. Ninety-two cases were identified over a period of 14 years and 10 months. Mean age was 8.2 years±3.4 years, ranging from 2.6 to 17.7 years of age. Sixty-three (68.5%) were boys. Most injuries occurred in streets (38.0%) and most children purposely picked up the needle (76.1%). Only 11 (12.0%) patients reported a syringe containing blood. Sixty-nine (75.0%) presented on the day of the injury. Among the 86 patients not known to have been previously vaccinated for HBV, 74 (86.0%) received HBIG and 83 (96.5%) received HBV vaccine. Seventy-two of the 83 (86.7%) who received HBV vaccine completed a 3-dose course in follow-up. Prophylactic antiretroviral therapy (ART) was offered as of 1998. Of the 51 patients who presented thereafter, 30 (58.8%) received ART, of whom 26 (86.7%) completed a four-week course of therapy. At 6 months, 62 were tested for HBV, 71 for HIV and 41 for HCV. There was no seroconversion. Fourteen patients were lost to our follow-up and testing is pending for 3 patients. The majority of pediatric NSI can be prevented. Therefore, children and parents need to be educated about the risks of discarded needles. Our study showed no infections in this setting.

Infection of patients by bloodborne viruses.

Despite taking precautions, healthcare workers performing invasive procedures run a small risk of infection by bloodborne viruses. When injury occurs, the viral status of the patient is often unknown and testing requires informed consent, which may be refused. On the other hand, although the chance of transmission of infection from a healthcare worker to a patient is extremely small, such personnel have an obligation of disclosure and, if seropositive, are barred from performing invasive procedures. The medical literature on bloodborne virus transmission between carers and patients was reviewed, and the UK Department of Health, General Medical Council and Royal College of Surgeons of England guidelines on the risk management of these infections were read, along with secondary references from all sources. Patients have complete protection of confidentiality and the right to refuse testing, but these rights do not apply to the healthcare worker. When injured in circumstances in which the patient cannot or will not permit testing, carers can only submit to the risks of prophylactic treatment or go into denial. Infection may have devastating professional, personal and financial implications to carers and their dependants. Ways to re-establish a just balance between the legitimate rights of patients and healthcare workers are discussed.

Unsafe injections in low-income country health settings: need for injection safety promotion to prevent the spread of blood-borne viruses.

Injections are one of the most frequently used medical procedures. The World Health Organization (WHO) estimates that 12 billion injections are given annually, 5% of which are administered for immunization and 95% for curative purposes. Unsafe injection practices (especially needle and syringe re-use) are commonplace in low-income country health settings, and place both staff and patients at risk of infection with blood-borne viruses (BBVs). It is estimated that up to 160000 human immunodeficiency virus (HIV), 4.7 million hepatitis C and 16 million hepatitis B infections each year are attributable to these practices. The problem is complex and fueled by a mixture of socio-cultural, economic and structural factors. An appropriate response on the part of international organizations, governments, health administrators, community organizations and health workers, including those who work in the area of HIV/AIDS prevention, has been slow to emerge. This paper reviews the literature relating to unsafe injection practices and the transmission of BBVs in low-income countries in order to raise awareness of the issue and the consequent need to promote injection safety messages amongst both consumers and providers of health care services in these countries. The nature and extent of unsafe injection practices, the burden of blood-borne viral illness attributable to unsafe injection practices, and the factors contributing to these practices are summarized, and possible strategies for promoting injection safety discussed.

Preventing cross infection of blood borne viruses on haemodialysis.

A chronic haemodialysis patient acquired hepatitis C. It was thought certain that this had occurred while dialysing in a satellite dialysis unit. The incident initiated a review of current measures in place to prevent the transmission of blood-borne viruses (BBV) on haemodialysis, with an analysis of current literature on the topic. It was found that the author's unit and several additional local units had no written protocols on prevention of BBV during haemodialysis, and methods of prevention were largely verbally communicated. A review of the literature gave conflicting opinions on the effectiveness of different measures to prevent cross-infection. Following the assessments and literature review, the appropriateness of certain preventative measures was looked at in more detail. A local protocol was subsequently developed and implemented at the author's Trust, which will significantly change practice in the haemodialysis unit.

HIV in prison: what are the risks and what can be done?

Prisons are recognised worldwide as important sites for transmission of blood-borne viruses (BBVs). There are two reasons why transmission risks in prison are higher than in the community. First, in most western countries, many prison entrants have histories of injecting drug use, and thus already have high prevalences of BBVs. Second, the lack or under-supply of preventive measures (such as clean needle and syringes or condoms) in most prisons, combined with extreme social conditions, creates extra opportunities for BBV transmission. HIV prevalence in prisoners in more developed countries ranges from 0.2% in Australia to over 10% in some European nations. There are case reports of HIV being transmitted by sharing injecting equipment and sexual activity. Tattooing has been reported as a risk factor for the transmission of BBVs in prison. Access to condoms and needle and syringe programmes in prisons is extremely limited, despite success when they have been introduced. The vast majority of prison inmates are incarcerated for only a few months before returning to the community--thus they are, over the long term, more appropriately regarded as 'citizens' than 'prisoners'. Public health policy must involve all sections of the community, including prison inmates, if we are to reduce transmission of HIV and other BBVs.

Emergence of the HIV type 1 epidemic in the twentieth century: comparing hypotheses to evidence.

The existence of multiple groups of HIV-1 and HIV-2 suggests that zoonotic transmissions of SIV have occurred at a low rate for centuries. Hence, an increase in the rate of human-to-human transmission may be necessary and sufficient to explain the emergence of HIV as an epidemic in the twentieth century. Three common hypotheses to explain accelerated transmission are (1) social changes accelerated sexual transmission, (2) health care changes accelerated parenteral transmission, and (3) serial passaging adapted HIV for persistent infection and sexual transmission. These hypotheses can be compared to a range of evidence. Temporal and geographic discontinuities in HIV epidemic growth are not easily explained by supposed increases in sexual transmission over time. Large historic changes in sexual transmission are hard to explain based on weak evidence associating HIV prevalence in African communities with differences in sexual behavior. On the other hand, documented iatrogenic outbreaks show high rates of parenteral transmission. The distribution of hepatitis C virus infections and the history of multiinjection treatment for trypanosomiasis in Central Africa suggest widespread parenteral transmission of blood-borne viruses during 1920-1940, coinciding in time and place with the early HIV epidemic. This suggests an important role for parenteral transmission in the early spread of HIV. Further research could improve our understanding of the early HIV epidemic.

A survey of doctors' and nurses' knowledge, attitudes and compliance with infection control guidelines in Birmingham teaching hospitals

This study investigated knowledge about infection control amongst doctors and nurses through a cross-sectional survey conducted between March and May 2001 in three Birmingham, UK teaching hospitals. Seventy-five doctors and 143 nurses, representing 7% and 4%, respectively, of potential respondents, participated in the study measuring knowledge of, attitudes towards, and compliance with universal precautions. Overall knowledge of risks of blood-borne virus (BBV) transmission from an infected patient after needlestick injury was low [44.0% for hepatitis B virus (HBV), 38.1% for hepatitis C virus (HCV), 54.6% for human immunodeficiency virus (HIV)]. There were significant differences between doctors and nurses concerning the estimations of HBV (e-antigen +) ( P=0.006) and HIV ( P<0.001) transmission risks. Eighty-six percent of nurses stated that they treat each patient as if they are carrying a BBV compared with 41% of doctors. Doctors and nurses differed significantly in their attitudes about and reported compliance with washing hands before and after patient contact and with wearing gloves when taking blood ( P<0.001 for all). Doctors consistently de-emphasized the importance of, and reported poor compliance with, these procedures. Doctors were also more likely to state that they re-sheath used needles manually than were nurses ( P<0.001). Thirty-seven percent of respondents reported that they had suffered a needlestick injury with a used needle, with doctors more likely to be injured than nurses ( P=0.005). Twenty-eight percent of these doctors and 2% of the nurses did not report their needlestick injuries ( P=0.004). Education, monitoring, improved availability of resources, and disciplinary measures for poor compliance are necessary to improve infection control in hospitals, especially amongst doctors.

On the Influence of the Risk of Virus Infections by Heat Sanitization of the PHD Hemodialysis Equipment

Virus infections, particularly the hepatitis viruses and HIV are constant threats to dialysis patients. There are no studies of the influence of heat sanitization of dialysis equipment. When multiple patients use a dialysis machine, the possibility of human blood-borne virus transmission exists. To assure the safety of the PHD we studied inactivation of several logs of viral infectivity, by the PHD disinfection process. Methods: Heated RO water was spiked with model viruses at 75°C ± 1°C and 82°C ± 2°C for 0, 20 and 45 minutes. As model viruses we used bovine viral diarrhea virus (BVDV)Ñ model for hepatitis C, hepatitis A virus (HAV), and porcine parvovirus (PPV). PPV is very robust and resistant to heat sanitaization procedures and served as the model for Hep-B and HIV that cannot be used in vitro studies. Results: 75C treatment instantaneously reduced the BVDVviral titer to non-detectable levels. HAV, one of the most robust viruses evaluated in viral clearance studies, was also reduced to non-detectable levels within 20 minutes. The PPV titer was reduced by approximately 5 log10 within 45 minutes. At 82°C ± 2°C, PPV was reduced to non-detectable levels within 20 minutes. Given that parvoviruses are the most robust viruses evaluated to date in viral clearance studies, the true potential of the treatment step to inactivate viruses is much greater than can be demonstrated. Conclusions: The heat treatment used by the PHD is very “robust”. Given that this study was performed at reduced temperature and time and that the typical PHD System disinfection temperature is 85°C ± 5°C for 1 hour, the convincing log10 reduction values for PPV not only demonstrate the safety of the PHD heat sanitization presently, but also provide a strong indication that the treatment will also inactivate other currently unknown viruses.

Psychometric properties of the Blood-borne Virus Transmission Risk Assessment Questionnaire (BBV-TRAQ).

To develop a standard measure of blood-borne virus transmission risk behaviour, and examine the underlying psychometric properties. The Blood-borne Virus Transmission Risk Assessment Questionnaire (BBV-TRAQ) was developed over three consecutive phases of the original BBV-TRAQ study in adherence to classical scale development procedures, culminating in the recruitment of a development sample of current injecting drug users via convenience and snowball sampling. Needle and syringe programmes (NSPs), medical clinics, alcohol/drug agencies, peer-based and outreach organizations across inner and outer metropolitan Melbourne. Two hundred and nine current injecting drug users. The mean age was 27 years, 68% were male, 65% unemployed, 36% with prison history and 25% in methadone maintenance. BBV-TRAQ items cover specific injecting, sexual and skin penetration risk practices. BBV-TRAQ characteristics were assessed via measures of internal and test-retest reliability; collateral validation; and principal components analyses. The BBV-TRAQ has satisfactory psychometric properties. Internal (a=0.87), test-retest (r=0.84) and inter-observer reliability results were high, suggesting that the instrument provides a reliable measure of BBV risk behaviour and is reliable over time and across interviewers. A principal components analysis with varimax rotation produced a parsimonious factor solution despite modest communality, and indicated that three factors (injecting, sex and skin penetration/hygiene risks) are required to describe BBV risk behaviour. The BBV-TRAQ is reliable and represents the first risk assessment tool to incorporate sufficient coverage of injecting, sex and other skin penetration risk practices to be considered truly content valid. The questionnaire is indicated for use in addictions research, clinical, peer education and BBV risk behaviour surveillance settings.

Nosocomial transmission of bloodborne viruses from infected health care workers to patients.

1Departments of Pathology and Laboratory Medicine, Medicine, and Microbiology and Infectious Diseases, University of Calgary, Calgary, Alberta; 2Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia Correspondence: Dr John Conly, Departments of Pathology and Laboratory Medicine, Medicine, and Microbiology and Infectious Diseases, Room 930, 9th Floor, North Tower, 1403 29th Street Northwest, Calgary, Alberta T2N 2T9. Telephone 403-944-8222, fax 403-944-1095, e-mail jconly@ucalgary.ca and Dr Lynn Johnston, Department of Medicine, Room 5014 ACC, Queen Elizabeth II Health Sciences Centre, 1278 Tower Road, Halifax, Nova Scotia B3H 2Y9. Telephone 902-473-5553, fax 902-473-7394, e-mail ljohnsto@dal.ca T risks to health care workers (HCWs) of occupationallyacquired infection with hepatitis B virus (HBV), human immunodeficiency virus (HIV) and, to a lesser extent, hepatitis C virus (HCV) have been reasonably well quantified (1). Evidence from the HIV and HBV experience suggests that the risk of infection is increased where the level of viremia is high, as manifested by high HIV viral load or the presence of hepatitis B e antigen (HbeAg) (1). It has also been recognized that patients may acquire one of these viruses following significant exposure to the blood of an infected HCW (2-4). While the magnitude of this risk to patients is considerably less than that to HCWs, the 1990 report by the Centers for Disease Control and Prevention (CDC) that a Florida dentist had transmitted HIV to patients in the course of dental care triggered widespread public concern about the risk of infection from HCWs. In 1991 CDC published recommendations for preventing HIV and HBV transmission to patients, which included the recommendation that HCWs who are infected with HIV or HBV (and HbeAg positive, a marker of higher infectivity) should not perform exposure-prone procedures unless they have sought counsel from an expert review panel (5). In 1998, Health Canada published guidelines for the management of HCWs infected with HBV, HCV, and/or HIV (6). Both these documents generated controversy at the time of their publication. Since that time, however, several provincial regulatory bodies have formed committees to advise physicians infected with these bloodborne pathogens (BBPs) regarding their practice. This article reviews what we know about the transmission of HBV, HCV and HIV from infected HCWs to patients in medical and dental settings.

The Sydney Medically Supervised Injecting Centre: a controversial public health measure.

Injecting drug use remains a major public health concern, particularly because of opiate overdose and transmission of blood-borne viruses. Sydney's Medically Supervised Injecting Centre (MSIC) opened on a trial basis in May 2001 in an effort to reduce the harms of drug use. In this report, we provide a brief overview of the reported public health impact of supervising injecting facilities (SIFs) and review the history and early process evaluations of the Sydney Centre. Medline, Internet searches and perusal of bibliographies of articles were used to identify key English language publications on SIFs. These were supplemented by interview with the Medical Director of Sydney MSIC, Dr Ingrid van Beek. It is difficult to be certain of the public health impact of SIFs but evidence from overseas and Sydney's early process evaluations provide promise that they may make a positive contribution to health.

Virus safety of human blood, plasma, and derived products

The reconstitution of blood and its components is hampered by factors of compatibility, availability, and the risk of transmission of infectious diseases. Protozoal agents such as plasmodium malariae and trypanosoma cruzi are only regionally relevant. Bacterial transmissions are easy to prevent and treat. Antibody, antigen, and nucleic acid screening have been implemented to prevent transmission of blood-borne viruses. Transfusion-relevant viruses include hepatitis B and C virus (HBV and HCV), human immunodeficiency virus (HIV), human T leukemia virus (HTLV-I), and in certain circumstances, parvovirus B19, hepatitis A virus (HAV), and cytomegalovirus (CMV). Of great concern is the possible transmission of prion protein causing transmissible spongiform encephalopathy. Of future interest will be whether other viruses such as Nipah and Hendra virus are blood-borne and whether viruses such as TT, SEN, and GBV-C are involved in diseases or their progression, while not causing hepatitis.

Detection of human herpesvirus 8 DNA in serum from blood donors with HHV-8 antibodies indicates possible bloodborne virus transmission.

Human herpesvirus 8 (HHV-8) is associated with Kaposi's sarcoma. There is a high seroprevalence of HHV-8 in several African countries, but the transmission route is not known definitively. In this study 174 serum samples from blood donors in Tanzania were examined by immunofluorescence assays detecting antibodies to latent and lytic HHV-8 antigens. Real-time polymerase chain reaction was used for detection and quantification of HHV-8 DNA in serum. In all, 83/174 (48%) of the subjects had antibodies to latent or lytic antigens. Forty (23%) had antibodies to both antigens and of those eight (20%) had detectable HHV-8 DNA in serum. HHV-8 DNA load correlated with antibody titres to lytic, but not latent, HHV-8 antigens. This supports the usefulness of anti-lytic antibodies in HHV-8 serology and suggests that transmission of HHV-8 by blood contact could be of importance in this region.

‘Covering All Points': conference review

T he Royal College of Surgeons in London played host in May to the ‘Covering All Points’ conference on the prevention of occupational blood-borne virus transmission in health care. The aim of the conference was two-fold. First, it considered how the number of accidents occurring in healthcare organisations could be measured accurately. It then discussed how to control and reduce the risks inherent in them.

Attitudes of novice heroin injectors towards non-injecting routes of administration to prevent the transmission of blood borne viruses

This study aimed to investigate attitudes towards and experiences with heroin use, by means other than injecting, in the West Australian city of Perth. As part of a major study of hepatitis C, injecting and the prevention of hepatitis C, a study group of 65 current drug injectors were invited to describe their experiences with heroin chasing, smoking or snorting and to discuss their attitudes towards the suggestion that using heroin by non-injecting methods could be utilised as a prevention strategy for hepatitis C. Experience with non-injecting (smoking or chasing) for the study group was limited, with less than half having initiated heroin use by non-injecting means and none having sustained the practice. Attitudes towards the promotion of non-injecting methods were largely negative. A small proportion of the study group expressed support for using non-injecting methods for health reasons, the majority being dismissive of the idea. The major barriers from the injectors’ perspective were seen to be related to cost and drug effect. A pre-existing barrier in Australia to using non-injecting methods is the predominance of salt of heroin, which does not lend itself to chasing or smoking. The results of this investigation are discussed in terms of the barriers to the promotion of non-injecting drug use and methods by which such barriers might be overcome to encourage a cultural change from heroin injection to non-injecting means of administration.

Surveillance and control of blood-borne virus infections in haemodialysis units

The risk of transmission of blood-borne viruses in renal dialysis units was reduced following the Rosenheim report recommendations issued in 1972. This document focused on the prevention and control of hepatitis B virus infections in renal dialysis and transplantation units. Good practice guidelines were produced, some of which may have been relaxed in conjunction with technological advances which included the use of disposable cartridges for haemodialysis. However, new viruses transmitted by blood and other body fluids have been identified over the years. A review of current practice for both patients and staff, together with updated good practice guidance, is necessary.

Exposure of healthcare workers in England, Wales, and Northern Ireland to bloodborne viruses between July 1997 and June 2000: analysis of surveillance data

The transmission of bloodborne viruses to healthcare workers can have serious consequences not only for clinical practice but also, because of the requirements of health and safety legislation, for their...