JOURNAL REVIEWS
May 1, 1999 4 minutes read
JOURNAL REVIEWS
Gerberding J. Provider-to-Patient HIV transmission: How to keep it exceedingly rare. Editor ial. Ann Intern Med 1999; 30:64-65.
Providers can transmit HIV to a patient during invasive procedures, but the probability of transmission is below the threshold of detection by even very intensive surveillance methods. In short, provider-to-patient HIV transmission is exceedingly rare in the United States, the author notes. She reviews the current status of this controversial issue in light of the recently reported case of provider-to-patient transmission in France and the 1990 dental transmission cases in the United States.
"The HIV epidemic has been raging for more than 20 years, and this formidable pathogen has infected millions of people," the author concludes. "It is reassuring that only two infected health care providers have been linked to patient infections. Rational prevention policies will further reduce this very small risk. Such policies can not only protect patients from infection but also protect their health care providers from unwarranted discrimination."
Such prevention approaches include the following elements:
• Injury prevention is the best strategy for preventing intraoperative HIV transmission among surgical personnel and their patients.
Surgery may not ever be completely free of risk, but it certainly can be much safer than was imagined even a decade ago. In many operating rooms, better hand protection; improved equipment design; and safer techniques for handling instruments, manipulating sutures, and closing wounds are now standard. Blunted suture needles also are gaining acceptance for many procedures.
• Intraoperative percutaneous blood exposures should be reported and managed in the same manner as other occupational exposures.
Some surgeons derive a false sense of security from the absence of documented occupational HIV infections attributable to suture needle injuries. Even though suture needle punctures probably transmit less blood than do hollow-bore needles, a low-volume exposure can contain blood with a very high titer of infectious HIV. Prompt reporting ensures access to appropriate exposure risk assessment, postexposure prophylactic antiretroviral treatment, and source patient testing for HIV and other bloodborne pathogens that affect follow-up care. Moreover, unreported exposures can result in undiagnosed infections and subsequent transmission to others.
• Surgeons and other health care providers who sustain frequent blood exposures should know their HIV status.
As was seen with the surgeon in the French case, failure to seek HIV testing can have dire consequences. Routine periodic testing may be a practical approach to ascertaining the HIV status of providers with frequent blood exposures, but it does not obviate the need for reporting discrete percutaneous exposures.
• Patient exposures to blood should be managed in the same manner as occupational exposures to blood.
When an intraoperative injury occurs, the accident should be reviewed to determine whether the patient was exposed to the injured provider’s blood. Mechanisms associated with such "recontacts" include passing the contaminated needle back through the patient’s tissue or sustaining an injury from bone or hardware imbedded in the patient. If recontact is probable, the provider should be tested for HIV; hepatitis C virus; and, if he or she is not known to be immune, hepatitis B virus, so the patient can receive appropriate follow-up care.
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Ippolito G, Puro V, Heptonstall J, et al. Occupational Human Immunodeficiency Virus infection in health care workers: Worldwide cases through September 1997. Clin Infect Dis 1999; 365-383.
All health care workers, regardless of job category or the health care setting in which they work, face a low but real risk of occupational infection from HIV exposure, the authors warn.
To characterize exposures resulting in HIV transmission, they reviewed available data on occupational cases reported worldwide, identifying 94 documented and 170 possible cases. The majority of documented infections occurred in nurses or clinical laboratory workers (66 of 94, 70.2%); after contact with infected blood (84 of 94, 89.4%); from a patient with AIDS (40 of 52, 76.5%); by percutaneous exposure (83 of 94, 88.3%); and during a procedure involving the placement of a device in an artery or vein (43 of 63, 68%).
High-exposure job categories (e.g., midwives and surgeons) represent the majority of possible cases. Transmission occurred through splashes, cuts, and skin contaminations, and in some cases despite postexposure prophylaxis with zidovudine.
"Health care workers could benefit if these data were incorporated in educational programs designed to prevent occupational bloodborne infections," the authors concluded.
Known cases are almost certainly under-reported because fewer than 5% of documented cases were reported from African countries, and there was a striking absence of reports of occupationally acquired infection from countries in the Indian subcontinent and Southeast Asia.
Infections most often occur following puncture injuries from blood-filled, hollow-bore needles but also have been caused by cuts from solid objects and contamination of non-intact skin or mucous membranes by at-risk biological substances. Adherence to universal precautions, modifications in procedural techniques, and improvements in the designs of sharp medical instruments are critical prevention measures for creating a safer workplace.
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