Treatment Of Genital Warts Research Articles

Immunotherapy of viral warts: myth and reality

Immunotherapy has become one of the most important therapeutic tools for the treatment of warts. At present, immunotherapy for warts is usually limited to recalcitrant lesions that are not responding to conventional therapy. Although there are a lot of immunotherapeutic regimens, a minority seem to be really effective. Moreover, there is a lack of evidence-based data on their effectiveness. Common immunotherapeutic modalities used for the treatment of warts include contact sensitizers, imiquimod, intralesional interferon, and oral drugs such as levamisole, cimetidine, and zinc sulfate. Intralesional antigens such as MMR (measles, mumps, and rubella) vaccine, skin test antigens (mumps, Candida, and Trichophyton), BCG (bacillus Calmette-Guιrin) vaccine, and Candida antigen were reported as successful treatment modalities in various forms of warts. Moreover, intradermal injection of some vaccines such as purified protein derivatives was also reported as a successful regimen for the treatment of genital warts. Among the available options for treatment of warts, none is uniformly effective or viricidal. Moreover, in most cases their safety and efficacy has not been assessed in double-blind, controlled clinical trials, and thus the reproducibility of many of the listed treatments is difficult to evaluate and a possible placebo effect cannot be ruled out. In this report, the various forms of immunotherapy for warts are discussed and each regimen is evaluated in order to assess the efficacy of each form of treatment.

Topical 20％ 5-aminolevulinic acid-based photodynamic therapy for the treatment of condyloma acuminatum of the vulva: a multicenter, randomized clinical evaluation of dose-response relationship

Objective To compare the safety and efficacy of two doses of topical 20％ 5-aminolevulinic acid (ALA) in photodynamic therapy (PDT) for condyloma acuminatum of the vulva on the premise that the area to be topically treated is fixed.Methods An open,randomized,parallel-group controlled clinical trial was performed in three institutions in eastern China.Patients with condyloma acuminatum of the vulva were randomly divided into two groups according to a random number table:group A and group B applying 0.5 ml and 0.25 ml of 20％ ALA solution,respectively,to an area measuring 2 cm in diameter followed by polyethylene film coating and adhesive tape fixation.All the patients were treated for three times with an interval of 7-10 days.Efficacy was evaluated and adverse reactions were recorded after each treatment,and follow-up was scheduled on week 1,4,8,12 and 24 after the last treatment for the observation of recurrence rate.Results A total of 88 patients with genital condyloma acuminatum were enrolled in this trail,and 81 patients completed all the treatment,including 45 patients with 55 warts in group A and 36 patients with 49 warts in group B.After 3 times of treatment,significant differences were observed in wart clearance rate (98.18％ vs.85.71％,,x2 =5.67,P ＜ 0.05) and cure rate (97.77％ vs.80.55％,x2 =6.66,P ＜ 0.05).The overall recurrence rate during 12 weeks after the last treatment was significantly lower in group A than in group B (9.09％ (4/44) vs.35.71％ (10.28),x2 =7.74,P＜ 0.01).Adverse reactions mainly included local swelling,pain and erosion,and all spontaneously subsided within 1 to 5 days.Further more,no significant difference was observed in the occurrence rate of adverse reactions between group A and B (33.33％ vs.30.55％,P ＞ 0.05).Conclusions Given that the area to be topically treated is fixed,0.5 ml of 20％ ALA is superior to 0.25 ml of 20％ ALA in the photodynamic treatment of condyloma acuminatum of the vulva with favorable efficacy,reduced recurrence and similar adverse reactions. Key words: Condylomata acuminata; Aminolevulinic acid; Photochemotherapy; Dose-response relationship,drug

Terapia combinada de criocirugía e interferón alfa-2b humano recombinante frente a criocirugía en el condiloma acuminado

IntroductionAlthough many options are available to eliminate condyloma acuminate lesions, none of them prevents relapses. Patients and methodA prospective, open, controlled study was carried out to compare the therapeutic effectiveness of cryosurgery plus interferon alfa-2b (IFN) versus cryosurgery alone in the treatment of condyloma acuminata. We included 170 adult patients with this diagnosis. There were 2 groups of 85 patients each. Patients from group i received IFN 3×106 IU 3 three times a week plus fortnightly application of cryosurgery. Patients in group ii received fortnightly application of cryosurgery alone. Treatment duration was the same (6 weeks) in each group. Therapeutic effectiveness was assessed 2 weeks after treatment completion by comparing the initial and final state of the lesions. Patients showing complete treatment response were followed up quarterly for 1 year to detect possible relapses. Relapse was the main outcome variable of this study. Adverse events were monitored throughout the study. ResultsRelapse rates were significantly lower in group i. The start-end comparative analysis showed a significantly better response to the treatment in group i. The most common adverse effects were fever, headache, chills and myalgias due to IFN and burning due to cryosurgery. None of these events was serious. ConclusionsCryosurgery plus IFN is more effective than cryosurgery alone. The combined treatments decreased the relapse rate from 83.1% to 2.6%. Adverse effects were mild or moderate and not serious.

Melanoma Arising after Imiquimod Use

Imiquimod belongs to the class of 1H-imidazo-[4,5-c]quinolones—drugs originally developed as nucleoside analogues with the aim of finding new potential antiviral agents (Harrison et al., 1988). Indeed, Imiquimod was first released as treatment for genital warts before its actions against skin cancer were studied. Imiquimod is a relatively small sized molecule (Mr = 240.3) and is hydrophobic, allowing it to penetrate the skin epidermal barrier and therefore making it suitable for topical formulations (Gerster et al., 2005). Imiquimod has shown itself effective against skin cancers and precancerous lesions, especially basal cell cancers and actinic keratosis (Salasche et al., 2002, Beutner et al., 1999). There have been reports of Imiquimod being used as topical treatment against cutaneous metastases of melanoma and some authors have reported its use as first-line therapy against melanoma in situ (Smyth et al., 2011, Gagnon, 2011). We report a case of an invasive malignant melanoma arising de novo at the specific site of application of Imiquimod (Aldara cream 5%) for a biopsy-proven superficial BCC. Therefore while Imiquimod has added to our topical armamentarium against skin cancer, care must be exercised in prescribing this treatment and it is especially important to follow up patients regularly.

Genital Warts in Infants and Children <br>—Re-Evaluation of Podophylline 15% as an Effective Topical Therapy

Background: Condylomataacuminata is an infection caused by Human Papilloma Virus, rarely reported in infants and children. Podophylline as a treatment for this condition has been used cautiously in this age group. Objective: To report the cases of anogenital warts including condy lomataacuminata in infants and children and to evaluate the effectiveness and side effects of 15% podophyllin in treatment of genital warts. Patient and Methods: Thirty infants and young children were seen in Department of Dermatology and Venereology—Baghdad Teaching Hospital in this case descriptive and therapeutic trial, in the period from January 2011 to August 2012. Their ages ranged from 8 - 72 (30.43 ± 15.85) months, 20 females and 10 males with a female:male ratio of 2:1. The duration of the disease ranged from 1 - 12 (5.26 ± 4.00) months. All demographics data were recorded in this study. History and examination were carried out to all patients. Family members including mothers were assessed about the presence of any type of viral warts in other location of body. Podophyllin (15%) in tincture benzoin was applied once weekly to all viral warts and the parents advised to wash out after 2 hours of application. The number of applications was repeated until full recovery. Follow-up after recovery was carried out for 6 months to watch for any relapse and to record local or systemic side effects. Results: The clinical pictures were mostly acondylomata acuminata in a form of cauliflower like warts in 20 (73.33%) patients, while in 10 (26.77%) patients there were ordinary verruca vulgaris like warts. The location of warts was perianal in 23 (76.66%) patients, genital only in 2 (6.66%) patients, and mixed in 5 (16.66%) patients. Topical applications of podophyllin 15% gave a full recovery in 27 (90%) patients, while in 3 (10%) patients there was partial response. The number of applications ranged from 1 - 4 (2.7 ± 1.42) applications. Follow up for 6 months after recovery showed relapse in only one patient, and no side effects were reported in any patients. Conclusion: There is upsurge of cases of anogenital warts among infants and children. Podophyllin (15%) in tincture benzoin is an effective therapy and no local or systemic side effects were recorded in any case.

Understanding genital warts: epidemiology, pathogenesis, and burden of disease of human papillomavirus.

As the most commonly sexually transmitted disease worldwide, human papillomavirus (HPV) infections are associated with significant morbidity and mortality. HPV infections most commonly affect young adults, women under 25 in particular. The most common risk factor for HPV infection in both sexes is a high number of lifetime sexual partners, whereas leading protective factors include circumcision, consistent condom use, and abstinence. Over 100 HPV types have been identified to date and are classified according to their level of oncogenic potential. HPV types 6 and 11 are responsible for approximately 90% of genital warts; HPV types 16 and 18 are responsible for 70% of invasive cervical cancers. External genital warts (EGWs) are the most common clinical manifestation of nononcogenic HPV infection. Coinfection with multiple HPV types is possible and may combine both low- and high-risk types, even in cases of genital warts. HPV infections are DNA viruses transmitted through skin-to-skin contact, invading the basal epithelial cells via microtears and evading the host immune response. Although non-life threatening, even low-risk HPV-type infections such as EGW carry a substantial psychosocial and economic burden. Stressors include the shame and embarrassment related to diagnosis, as well as the inconvenience and discomfort of treatment and the fear of recurrence, transmission, and the possible threat of cancer. Costs relate to routine screening for cervical cancer, treatment of genital warts, and the management and follow-up of malignancies.

Gesichertes und Neues bei der Therapie von Condylomata

Anogenital warts are the most common clinical manifestation of human papillomavirus (HPV) infections. Although easy to recognize, asymptomatic anogenital warts (condylomata acuminata) may be overlooked, leading to unaware transmission to the sexual partner. On the other hand awareness of this sexually transmitted disease (STD) is largely associated with a great psychological and social burden, in men as well as women. Spontaneous regression of genital warts has been observed mostly within 2-5 years; however, persisting condylomata may prove refractory to all current treatment options. Because removal of the warts does not totally eliminate the underlying viral infection, treatment of genital warts can often be of long duration, of varying effectiveness and with high recurrence rates. Without a doubt only the patient's own immune system is capable of clearing HPV infections. Therefore, the solution to one of mankind's oldest health problems will depend on the future acceptability of HPV vaccines.

P2.178 Condyloma Acuminata, Treatment with Liquid Nitrogen and TCA

Condyloma acuminata is the infection caused by Human Papilloma virus. Condyloma acuminate are soft, skin coloured, fleshy warts, can appear solitary or in a group and can be both small...

Imiquimod, Molluscum, and the Need for a Better “Best Pharmaceuticals for Children” Act

* Abbreviations: BPCA — : Best Pharmaceuticals for Children Act FDA — : Food and Drug Administration MC — : Molluscum contagiosum PI — : package insert RCT — : randomized controlled trial It was the best research Emily’s doctor had never heard about.* Emily was a delightful 6-year-old with molluscum contagiosum (MC). Characteristic dome-shaped umbilicated papules, some of them itchy, peppered her chest and buttocks. Emily had returned to the clinic, where one of us (KAK) saw her, after she failed treatment with imiquimod 5% cream. Coincidentally, Emily was born just as 2 rigorously conducted randomized controlled trials (RCTs) of imiquimod for treatment of MC in children were concluding. In both studies, imiquimod proved ineffective. Six years later, and 5 years after imiquimod’s package insert (PI) had been updated to include those RCT results, no studies had shown otherwise. So why was Emily prescribed imiquimod? It would be easy to blame Emily’s doctor. But it’s not that simple. The real problem lies in a federal law that allows data from pediatric drug studies requested by the federal government and subsidized by taxpayers to escape meaningful dissemination to physicians. As a result, children like Emily are needlessly exposed to ineffective and/or unsafe medicines. Imiquimod was first approved by the Food and Drug Administration (FDA) for treatment of genital warts in adults in 1997. Physicians soon began using it off-label to treat MC in children. There were good reasons for that. First, other treatments were inconvenient and/or poorly tolerated. Second, imiquimod had proven effective for genital warts, which like MC are caused by a virus. Third, numerous observational studies and review articles, as well as 2 small RCTs, suggested that imiquimod might work. But the evidence was not … Address correspondence to Kenneth A. Katz, MD, MSc, MSCE, The Permanente Medical Group, Inc., 7601 Stoneridge Dr, Second Floor, Pleasanton, CA 94588. E-mail: kenneth.katz{at}gmail.com

O08.6 Do You Have an STI? Findings from a Dedicated Men’s Sexual Health Clinic in Alexandra Township, South Africa

BackgroundA walk-in weekly men’s sexual health clinical service, provided by a male clinical team, was established in 2006.MethodsWe analysed new patient episodes at a dedicated men’s sexual health clinic in...

Current update on the treatment of genital warts

External genital warts (EGW) are currently the most common form of viral sexually transmitted disease found in the general population. EGW have been shown to occur as a direct result of infection with the human papillomavirus (HPV). Malignancy is typically associated with high-risk types of HPV; however, low-risk type association has been observed. Numerous therapies are presently indicated for use in the treatment of EGW, which can target lesions through multiple modalities including topically, surgically or via immune modulation. Therapies often differ dramatically with respect to cost, side-effect profiles, dosing schedules, duration of treatment and overall effectiveness. Routine HPV vaccination may play a powerful role in reducing the burden of disease by preventing viral infection and transmission. As HPV vaccination continues to gain widespread approval, it may prove instrumental in decreasing the incidence of HPV infection and eventually eradicating genital warts.

5‐aminolevulinic acid‐based photodynamic therapy for the treatment of condylomata acuminata in Chinese patients: a meta‐analysis

This meta-analysis was designed to assess the efficacy of topical 5-aminolaevulinic acid (ALA) photodynamic therapy (PDT) in Chinese patients with condylomata acuminata (CA). Electronic literature databases (Medline, Embase, Cochrane Library, China National Knowledge Infrastructure, and Wanfang database) were searched for relevant randomized controlled trials (RCTs) published prior to October 2012. Only RCTs that compared ALA-PDT to non-ALA-PDT for patients with genital condylomata were selected. The outcomes included the recurrence rate and adverse events. The risk ratios (RRs) and 95% confidence intervals (CIs) were calculated as the ALA-PDT vs. without ALA-PDT. Twenty RCTs composed of 1903 patients (ALA-PDT, n = 1106; non-ALA-PDT, n = 797) were included in the meta-analysis. ALA-PDT decreased the recurrence rate within 12 week after treatment (vs. without ALA-PDT, RR: 0.28, 95% CI: 0.22-0.35) and 24 week after treatment (vs. without ALA-PDT, RR: 0.24, 95% CI: 0.17-0.34) in a fixed-effect model. The common adverse events related ALA-PDT included a mild burning and/or stinging sensation, erythema, mild edema, erosion, and hyperpigmentation. Local application of ALA-PDT reduced recurrence rate vs. without ALA-PDT. The use of ALA-PDT should be considered as a feasible therapy for the treatment of CA.

Basic Therapeutic Principles and the Strategy in the Management of the External Anogenital Warts (Condylomas): A Review

Genital warts are a highly contagious sexually transmitted disease involving the anogenital area. They are considered to be benign proliferative conditions as a result of an infection with a low risk human papillomavirus (HPV). The goal of this paper is to review recent available clinical data, and present an overview and strategy in the diagnosis and treatment of genital warts. Med-line search was conducted and published papers related to anogenital warts were reviewed. Treatment results differ and are directly related to the characteristics of the lesion, the patient ’ s immune response and the expertise of the health provider. Smaller lesions are more amenable and respond to local treatment compared to larger and more extensive lesions. Although genital warts are generally a benign disease, however infection with certain types of HPV may increase the risk of premalignant disease. Treatment decisions are based on the number, location, morphology of the lesion and patients ’ co-existent medical conditions and their preferences for available treatment modalities. Important issues in the diagnosis and management of genital warts are discussed and specific recommendations are presented. doi: http://dx.doi.org/10.4021/jcgo86e

Needle-free injection of 5-aminolevulinic acid in photodynamic therapy for the treatment of condylomata acuminata

The external application of 5-aminolevulinic acid (ALA) in photodynamic therapy (PDT) results in a shallow penetration depth in thick or extensive condylomata acuminata (CA) lesions, thus demonstrating a poor therapeutic effect for those patients. To compare the efficacy of needle-free injection with external application of ALA in PDT for the treatment of CA, 160 CA patients with thick or extensive warts received ALA-PDT by means of external application or needle-free injection of ALA, respectively. The complete response (CR) rate and recurrence rate in the two groups were analyzed. The CR rate after the first treatment in the needle-free injection group (68.8%) was significantly higher compared with that in the external application group (52.5%; P=0.035). The recurrence rates in the needle-free injection group and external application group were 4.1 and 15.4%, respectively (P=0.022). The needle-free injection of ALA increases the therapeutic effect of PDT for CA patients with thick or extensive lesions. It shortens the treatment time and reduces the recurrence rate, and has great potential in the treatment of CA.

Adverse Psychosexual Impact Related to the Treatment of Genital Warts and Cervical Intraepithelial Neoplasia.

Objective. To compare the psychosexual impact related to the treatment of genital warts and cervical intraepithelial neoplasia (CIN) in women. Methods. 75 patients presenting with HPV-induced genital lesions, belonging to one of two patient groups, were included in the study: 29 individuals with genital warts (GWs) and 46 individuals with CIN grades 2 or 3 (CIN 2/3). Initially, medical charts of each woman were examined for extraction of data on the type of HPV-induced infection and treatment administered. Subjects were interviewed to collect sociodemographic data as well as personal, gynecologic, obstetric, and sexual history. After this initial anamnesis, the Sexual Quotient-Female Version (SQ-F) questionnaire was applied to assess sexual function. After application of the questionnaire, patients answered specific questions produced by the researchers, aimed at assessing the impact of the disease and its treatment on their sexual lives. Results. It is noteworthy that patients with CIN 2/3 had statistically similar classification of sexual quotient to patients with GWs (P = 0.115). However, patients with GWs more frequently gave positive answers to the specific questions compared to patients with CIN 2/3. Conclusion. Based on these findings, it is clear that GWs have a greater impact on sexual behavior compared to CIN 2/3.

Decline in in-patient treatments of genital warts among young Australians following the national HPV vaccination program

BackgroundThere has been a rapid decline in the number of young heterosexuals diagnosed with genital warts at outpatient sexual health services since the national human papillomavirus (HPV) vaccination program started in Australia in 2007. We assessed the impact of the vaccination program on the number of in-patient treatments for genital warts.MethodsData on in-patient treatments of genital warts in all private hospitals were extracted from the Medicare website. Medicare is the universal health insurance scheme of Australia. In the vaccine period (2007–2011) and pre-vaccine period (2000–2007) we calculated the percentage change in treatment numbers and trends in annual treatment rates in private hospitals. Australian population data were used to calculate rates. Summary rate ratios of average annual trends were determined.ResultsBetween 2000 and 2011, 6,014 women and 936 men aged 15–44 years underwent in-patient treatment for genital warts in private hospitals. In 15–24 year old women, there was a significant decreasing trend in annual treatment rates of vulval/vaginal warts in the vaccine period (overall decrease of 85.3% in treatment numbers from 2007 to 2011) compared to no significant trend in the pre-vaccine period (summary rate ratio (SRR) = 0.33, p < 0.001). In 25–34 year old women, declining trends were seen in both vaccine and pre-vaccine periods (overall decrease of 33% vs. 24.3%), but the rate of change was greater in the vaccine period (SRR = 0.60, p < 0.001). In 35–44 year old women, there was no significant change in both periods (SRR = 0.91, p = 0.14). In 15–24 year old men, there was a significant decreasing trend in annual treatment rates of penile warts in the vaccine period (decrease of 70.6%) compared to an increasing trend in the pre-vaccine period (SRR = 0.76, p = 0.02). In 25–34 year old men there was a significant decreasing trend in the vaccine period compared to no change in the pre-vaccine period (SRR = 0.81, p = 0.04) and in 35–44 year old men there was no significant change in rates of penile warts both periods, but the rate of change was greater in the vaccine period (SRR = 0.70, p = 0.02).ConclusionsThe marked decline in in-patient treatment of vulval/vaginal warts in the youngest women is probably attributable to the HPV vaccine program. The moderate decline in in-patient treatments for penile warts in men probably reflects herd immunity.

Clinical and immunologic results of local hyperthermia at 44 °C for extensive genital warts in patients with diabetes mellitus

Background: Genital warts are more extensive and difficult to treat in patients with diabetes mellitus due to defective immune responses.Purpose: Our aim was to confirm the suitability of local hyperthermia for the treatment of genital warts in patients with diabetes mellitus and to investigate the immune cells in lesional areas at different time intervals after treatment.Methods: We treated three diabetic patients with extensive genital warts by local hyperthermia at 44 °C for 30 min a day for 3 consecutive days plus 2 additional days 1 week later, then once a week till there showed signs of clinical clearance. Immunohistochemical profile was described on serial biopsies from a patient with confluent plaques.Results: The warty lesions in the patients resolved in 6, 4 and 9 weeks, respectively. Immunohistochemical staining in the regressing warts revealed abundant infiltrating CD4+ T and CD8+ T lymphocytes (P < 0.01), as well as macrophages and CD1a+ dendritic cells.Conclusions: This preliminary study suggested that local hyperthermia was a safe and effective single modality in the treatment of genital warts in diabetic patients and could induce a rapid immune response in lesional skin.

Update on the treatment of genital warts

This review summarizes new treatments from the last seven years employed for the treatment of genital warts caused by human papillomavirus (HPV). Imquimod 3.75% is a new agent with fewer side effects and perhaps a better dosing schedule than imquimod 5%, but is not more effective. Sinecatechins/Polyphenon E 15%, a novel extract from green tea can be effective against genital warts but requires three times a day dosing and is not more effective than existing treatments; the treatment course is 12-16 weeks. Photodynamic therapy combined with other destructive modalities might increase the cure rate for genital warts. The quadrivalent vaccine against HPV 6, 11, 16, 18 is decreasing the incidence of warts in the western world but the evidence does not support vaccination as a treatment for those already infected by HPV. Hyperthermia and immunomodulators might be positive additions to the armamentarium of clinicians. In sum, there are new tools that physicians can use but none is really a great advance over what was available a decade ago.

A rapid and validated reverse phase liquid chromatographic method for determination of imiquimod from topical cream formulations

A Novel, rapid, accurate and precise reverse phase isocratic HPLC method has been developed for the determination of Imiquimod content in Imiquimod cream which is widely used for treatment of precancerous skin lesions known as actinic keratosis, a certain type of skin cancer and treatment of genital warts, known as Human Papilloma Virus (HPV). A mixture of 10 mM monobasic phosphate containing 0.1% triethylamine adjusted to pH 2.45 and acetonitrile in the ratio of 70:30 (v/v) was used as mobile phase. C-18 column of dimension 250 × 4.6 mm, 5 μ from Inertsil was used for analysis. Detector wavelength was kept at 245 nm and flow rate was kept 1.4 mL min−1. The retention time was observed at about 3.0 ± 0.1 min. The method has been validated as per ICH guidelines, with respect to specificity, linearity, accuracy, precision, robustness, solution stability and filter compatibility. Results for all the parameters were found within predetermined limits. The proposed method was applied to determine the content of Imiquimod in Imiquimod creams from different manufacturers. Content of the imiquimod was in good agreement with label claim of Imiquimod creams. This showed that proposed method is rapid, simple, precise, linear, robust, rugged and accurate which is useful and economic for routine analysis of Imiquimod content in Imiquimod cream.

Transmission of human papillomavirus DNA from patient to surgical masks, gloves and oral mucosa of medical personnel during treatment of laryngeal papillomas and genital warts

The risk of occupational human papillomavirus (HPV) transmission from patient to medical personnel during laser vaporization procedures remains controversial. The purpose of this study was to determine the risk of HPV transmission from the patient to the protective surgical masks, gloves and oral mucosa of medical personnel during the treatment of laryngeal papillomas and genital warts. The study involved five male patients scheduled for the surgical treatment of laryngeal papillomas, and five male patients undergoing carbon dioxide (CO(2)) laser treatment for urethral warts. Oral mucosa specimens were obtained from the study patients and the employees pre- and postoperatively. Samples were collected from the HPV-infected patient tissue, and from the surgical masks and gloves used by the employees. A total of 120 samples were analyzed for the presence of HPV DNA by PCR, using the degenerated MY09/11/HMB01 primers. After the papilloma procedures, the surgeons' gloves tested HPV positive in one of the five cases and those of the surgical nurse in three of the five cases. After the treatment of genital warts, HPV DNA corresponding to the patient tissue specimens was present in all the samples obtained from the surgical gloves of the operators. All oral mucosa samples obtained from 18 different employees tested HPV negative, as did the surgical mask specimens. According to our study, HPV may contaminate protective equipment, most of all surgical gloves, but transmission of HPV DNA to medical personnel is unlikely to occur provided that protective surgical gloves and masks are applied and disposed of properly.