Management Of Healthcare Workers Research Articles

Management of healthcare workers after occupational exposure to hepatitis C virus

Management of healthcare workers after occupational exposure to hepatitis C virus

Management of Health Care Workers With Blood-Borne Infections—Reply

Management of Health Care Workers With Blood-Borne Infections—Reply

Management of Health Care Workers With Blood-Borne Infections

Management of Health Care Workers With Blood-Borne Infections

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.

HIV postexposure prophylaxis for children and adolescents

HIV postexposure prophylaxis (PEP) is now a well-established part of the management of health care workers after occupational exposures to HIV. Use of PEP for adults exposed to HIV after sexual contact or injection drug use in nonoccupational settings remains controversial with limited data available. There is even less information available concerning HIV PEP for children and adolescents after accidental needlestick injuries or sexual assault. The objective was to describe the current practice of and associated problems with HIV PEP for children and adolescents at an urban academic pediatric emergency department. A retrospective review of all children and adolescents offered HIV PEP between June 1997-June 1998 was conducted. Ten pediatric and adolescent patients were offered HIV PEP, six patients after sexual assault, four patients after needle stick injuries. There were two small children 2 and 3 years of age and eight adolescents. Of these 10 patients, eight were started on HIV PEP. The regimens used for PEP varied; zidovudine, lamivudine, and indinavir were prescribed for in seven patients and zidovudine, lamivudine, and nelfinavir for one other. All 10 patients were HIV negative by serology at baseline testing and all available for follow-up testing (5 of 10) remained HIV negative at 4 to 28 weeks. Only two patients completed the full course of 4 weeks of antiretroviral therapy. Financial concerns, side effects, additional psychiatric and substance abuse issues as well as the degree of parental involvement influenced whether PEP and clinical follow-up was completed. HIV PEP in the nonoccupational setting for children and adolescents presents a medical and management challenge, and requires a coordinated effort at the initial presentation to the health care system and at follow-up. The difficulties encountered in the patients in our series need to be considered before initiating prophylaxis. A provisional management approach to HIV PEP in children and adolescents is proposed.

Prevention of occupationally acquired infections among heath-care workers.

1. Chia Yin Chong, MBBS* 2. Donald A. Goldmann, MD† 3. W. Charles Huskins, MD, MS† 1. 2. *Division of Infectious Diseases, Children’s Hospital, Boston, MA. 3. 4. †Division of Infectious Diseases and Department of Pediatrics, Harvard Medical School, Boston, MA. 1. Health-care workers should have immunity to five vaccine-preventable diseases (measles, mumps, rubella, varicella, hepatitis B) determined during preplacement screening. 2. Health-care workers who have been exposed to active pulmonary or laryngeal tuberculosis and do not have a previous history of a positive purified protein derivative (PPD) or treatment for tuberculosis should have PPD skin tests performed at baseline; if negative, they should be repeated 12 weeks after exposure. 3. Health-care workers should receive annual vaccination against influenza because they care for patients who may be at high risk for serious morbidity and mortality from influenza, because immunity to particular subtypes of influenza is relatively short-lived, and because the antigenic composition of circulating subtypes changes from year to year. 4. A detailed history is required to determine the appropriate management of health-care workers who have suffered a percutaneous exposure to blood and should include the depth of penetration, the type of instrument causing the injury, previous contact of the instrument with the source patient’s blood, a history of documented infection or risk factors for infection with a bloodborne virus in the source patient, and a detailed history of hepatitis B vaccination of the worker. 5. The efficacy of postexposure prophylaxis for human immunodeficiency virus infection has not been established, but it is supported by several indirect lines of evidence. Hospitals and medical clinics are favorable settings for the transmission of infectious diseases because infected and susceptible persons are brought into close proximity. Health-care workers (HCW) are at particular risk because their work demands close contact with patients who may be harboring pathogenic microorganisms. This article focuses on the prevention of occupationally acquired infectious diseases among HCW, although it should be recognized that a comprehensive occupational health program also reduces the risk of hospital-acquired infection among patients. Occupational infections among microbiology laboratory workers that are not …

Time course of viremia and antibody seroconversion following human immunodeficiency virus exposure

Rational application of diagnostic assays in the management of healthcare workers (HCWs) following occupational exposure is needed to rule out pre-existing human immunodeficiency virus (HIV) infection, detect HIV infection or seroconversion as early as possible in the small proportion individuals who become infected, and to rule out infection in the high proportion of individuals who remain uninfected following occupational exposure to HIV. An understanding of the time course of viremia and seroconversion following HIV exposure is essential in developing recommendations for management of occupational exposure among HCWs. Several data sources that address the timing and dynamics of HIV viremia and seroconversion following primary infection are reviewed. The implications of each data source for management of occupational exposure among HCWs is assessed. Although the majority of infected HCWs seroconvert within 2 months of exposure, the possibility of delayed seroconversion is well established, with approximately 5% of infected HCWs estimated to seroconvert >6 months after exposure. In contrast, the period of viremia (detectable by p24 antigen or RNA assays) preceding antibody seroconversion is consistently brief (1-3 weeks). Animal inoculation studies indicate that a variable period of localized viral replication in lymphoid tissue draining inoculation sites exists prior to systemic viremia and subsequent seroconversion.

Management of healthcare workers with pharyngitis or suspected streptococcal infections.

The group A streptococcus may cause pharyngitis, rheumatic fever, streptococcal toxic shock syndrome, and serious skin and soft-tissue infections. More than 50 nosocomial outbreaks have been reported since 1966. For this reason, healthcare facilities should develop policies for the diagnosis and treatment of symptomatic hospital employees, and for the recognition and management of potential outbreaks. The clinical diagnosis of streptococcal pharyngitis is unreliable. Rapid streptococcal tests may be used for initial screening, but a negative rapid test should be confirmed with a properly obtained culture. Penicillin remains the treatment of choice, but new alternatives now include a 5-day course of either azithromycin or cefpodoxime.

Management of Healthcare Workers with Pharyngitis or Suspected Streptococcal Infections

The group A streptococcus may cause pharyngitis, rheumatic fever, streptococcal toxic shock syndrome, and serious skin and soft-tissue infections. More than 50 nosocomial outbreaks have been reported since 1966. For this reason, healthcare facilities should develop policies for the diagnosis and treatment of symptomatic hospital employees, and for the recognition and management of potential outbreaks. The clinical diagnosis of streptococcal pharyngitis is unreliable. Rapid streptococcal tests may be used for initial screening, but a negative rapid test should be confirmed with a properly obtained culture. Penicillin remains the treatment of choice, but new alternatives now include a 5-day course of either azithromycin or cefpodoxime.

Institutional Control Measures for Tuberculosis in the Era of Multiple Drug Resistance: ACCP/ATS Consensus Conference

Institutional Control Measures for Tuberculosis in the Era of Multiple Drug Resistance: ACCP/ATS Consensus Conference

Management of health care workers after inadvertent exposure to tuberculosis: a guide for the use of preventive therapy.

To quantify the protection of previously infected persons from developing tuberculosis after intense exposure. 6 hospitals and 22 nursing homes in which heavy tuberculosis exposure had occurred. Results of tuberculin skin tests before and after exposure and the development of tuberculosis among known reactors, both converters and nonconverters. All converters were given preventive therapy with isoniazid as soon as they could be identified. Nonconverters and previously known reactors were not treated. In 6 hospital outbreaks, largely aborted by prompt preventive therapy, 98 of 336 nonreactors (29%) showed skin test conversion, and, before therapy could be started, 19 (19% [95% CI, 12% to 29%]) had developed tuberculosis. No tuberculosis developed among the 238 nonconverters (0% [CI, 0% to 1.5%]) or the 76 known reactors who were not treated (0% [CI, 0.5% to 2%]). Tuberculosis developed in 5 of 209 known reactors (2.4% [CI, 0.8% to 5.5%]) in 22 nursing homes with heavy exposure, little more than 10 of 921 known reactors (1.1% [CI, 0.5% to 2%]) in 76 homes where there was no exposure (P = 0.17). Healthy persons who remain nonreactive to tuberculin after heavy exposure have escaped infection and require no chemotherapy. However, if exposure is discovered immediately, it is wise to start preventive therapy in particularly heavily exposed non-reactors and discontinue it if the skin test result is still negative at 3 months. Persons who react after exposure fall into three groups: 1) converters, in whom the risk for tuberculosis warrants preventive chemotherapy, regardless of age; 2) reactors with no preexposure test results, who should be treated as converters; and 3) previously known reactors, in whom the risk for tuberculosis generally is too slight to warrant therapy. However, those who are younger than age 35 years, have human immunodeficiency virus infection, are receiving cancer chemotherapy or long-term corticosteroid therapy, or are otherwise immunocompromised should be considered for preventive therapy, regardless of the exposure.

The seroprevalence of hepatitis B and C in hospitalized Danish patients.

Health care workers are at risk of acquiring blood-borne infections. To assess the risk of exposure to hepatitis B or C in the case of occupational blood exposure, we determined the seroprevalence of these infections in 466 patients admitted to a Copenhagen university hospital. Serological markers for hepatitis B or C were detected in 56 patients (12.0%). The seroprevalence of HBsAg and anti-HCV was 0.9% and 1.5% respectively. HCV RNA, indicating ongoing hepatitis C, was found in five of seven anti-HCV-positive patients by polymerase chain reaction. The serological findings had not previously been diagnosed in 4 of 10 potentially infectious patients and only 6 of 10 patients belonged to high-risk groups. In conclusion, health care workers should be aware of the potential the occupational risk of hepatitis B and C even in a low-prevalence country like Denmark. Management of health care workers after blood exposure should include serological testing for both hepatitis B and C. Strict adherence to universal precautions is recommended and vaccination against hepatitis B should be encouraged.

Problems in management of health care workers exposed to HBeAg positive body fluids

A young Asian male was admitted to hospital suffering from severe lower limb and facial injuries. He was subsequently found to be a carrier of hepatitis B virus and HBeAg positive. The management of 38 health care workers with significant blood and body fluid exposure involving this patient is discussed.

MUSCULOSKELETAL DEVELOPMENT. A REVIEW

The early development of the limbs, the skeletal and muscular systems, and the joints and early changes in joint mobility are reviewed. The musculoskeletal system is vulnerable to failures of specific morphogenetic processes in the embryonic period. Congenital anomalies and postural deformities also may arise in the fetal period. Awareness of prenatal and postnatal events and their timing will assist health care workers in management of pediatric clients.

Zidovudine for chemoprophylaxis after occupational exposure to HIV-infected blood: an economic evaluation.

Three approaches to the management of health care workers (HCWs) following percutaneous exposure to blood of previously unknown serological status were compared using cost-effectiveness analysis. In strategy A, all HCWs are offered zidovudine as soon as possible after exposure. The decision is made within 72 hours to (1) continue therapy with the drug for 4 weeks if the patient's blood is positive for human immunodeficiency virus (HIV) on testing or (2) discontinue therapy and follow-up if the patient's blood is HIV-negative. Strategy B is similar to A except that zidovudine is not offered. In strategy C the patient's blood is not tested and zidovudine is not offered. The results indicate that for every 100 HCWs managed with strategies A, B, and C, the total costs in Canadian dollars (Can $1.00 = U.S. $0.85) are $47,910, $38,849, and $110,834, respectively. The incremental cost per case of AIDS prevented by A relative to B is $300,140, and that prevented by A relative to C is -$6,244,000 (i.e., A results in savings relative to C).

Musculoskeletal Development: A Review

The early development of the limbs, the skeletal and muscular systems, and the joints and early changes in joint mobility are reviewed. The musculoskeletal system is vulnerable to failures of specific morphogenetic processes in the embryonic period. Congenital anomalies and postural deformities also may arise in the fetal period. Awareness of prenatal and postnatal events and their timing will assist health care workers in management of pediatric clients.

The epidemiology of HIV infection, AIDS, and health care worker risk issues.

Acquired immunodeficiency syndrome (AIDS) has been a silent epidemic for 22 years. The 1st documented isolate of the human immunodeficiency virus (HIV) was detected retrospectively in a blood specimen from a young Central African man who had participated in a study in 1959. AIDS cases were 1st reported in 1981. 2 factors kept the AIDS epidemic silent: 1) the long incubation period between the initial infection and the onset of disease; and 2) the relatively recent intrusion of the virus into developed nations. Almost 100,000 people in the US now have AIDS. AIDS was found to be transmitted by blood; therefore, there is concern among health care workers (HCWs) about the risk of AIDS transmission. In the US, AIDS was 1st described in 1981 in 5 sexually active homosexual young men in Los Angeles. Soon, AIDS was describe in clusters of patients in other cities. It is defined as many unusual infections or cancers that suggest a poorly functioning immune system for which no other cause can be found. Statisticians with the US Public Health Service have used mathematical models to estimate the magnitude of HIV infection in the US. They currently estimate this to be 1-1.5 million infected persons. AIDS is not spread by casual transmission. The 3 established transmission routes--sex, contact with blood, and being born to an infected mother--are not equally efficient. It is estimated that all infected persons will sooner or later become seriously ill with HIV-related disease. To date, only 1 drug (Azidothymide or AZT) has been licensed as an effective antiviral drug. In April, 1988 the Centers for Disease Control (CDC) reported that HCWs developed AIDs with the same statistical frequency as the rest of the general population. The number of HCWs who have developed disease as a result of occupational exposure is so small that it is statistically undetectable. This does not mean there is no risk for occupational infection, but only that it is a relatively low risk for most HCWs. The major risk for transmission of HIV infection to HCWs is associated with handling sharp instruments. The major preventive effort should be directed at this problem. The CDC has suggested a system of infection precautions called "Universal Precautions" to protect HCWs from HIV infection. Another approach is "Body Substance Isolation." It is intended to be a complete isolation and precautions system. Reusable instruments should receive disinfection. Management of HCWs with potential exposure to HIV is discussed.

The management of health care workers' accidental parenteral exposures to biological specimens of HIV seropositive individuals.

Health care workers can reduce risks associated with caring for HIV seropositive individuals by strict adherence to routine infection control procedures. Educating personnel in infection control should be increasingly stressed in all health-related settings. When accidents occur, however, the health care industry must respond with appropriate care and follow-up of their employees. The outlined approach for the management of health care workers with needlestick injuries from HIV-contaminated biological specimens provides increased follow-up for workers at higher risk (those who develop illness in the months following an exposure) than current CDC guidelines; and less but sufficient follow-up of those who have a lower risk (no illness) of acquiring HIV infection. Overall, this protocol will provide a more economical, practical, and medically adequate method for follow-up of exposed health care personnel.