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%03Epidemiology of Perioperative Bloodborne Infections,   6UCSF Department of Surgery Grand Rounds March 29, 2006Case I was putting in an IV catheter in a patient who lost access. As I took the needle out, my fingertip hit the tip of the needle and punctured my skin. It bled spontaneously. I knew the patient was Hepatitis C and HIV positive&  Sulkowski, MS et al. JAMA 2002 <    Brief OutlinexHIV, Hepatitis B, Hepatitis C Surveillance and Reporting Systems Exposure Data from OR Data from Developing Countries(Zy  HIV*HIV risk from patient to surgeon is low No difference in HIV infection between HCW s and population 138 individuals with probable occupationally acquired HIV infection: 6 surgeons 56 HCW s w/documented seroconversion after percutaneous exposure (0 surgeons) PEP recommended h(<PN(POe )   Hepatitis B1.25 million people in US w/chronic HBV 5% of acute HBV -> chronic HBV HBV transmission is 30% cases when naive host has hollow bore needle stick from chronically infected patient Must confirm effective immunization Many surgeons check titers q 10 years HZZmZZ$Z&ZZ{6$  &  Hepatitis Cc4 million in US w/ chronic HCV 75% acute HCV clinically occult (like HBV) 50-80% acute HCV become chronic Up to 20% chronic HCV advance to cirrhosis 0.5% rate of conversion after hollow bore needle sticks (new data: from 1.8%) May require 1 year of testing after exposure to convert HCV blood exposure to conjunctiva = transmission risk of HCV needlestick:JKJKX 3Worldwide healthcare worker to patient transmission44(51991-2005 (Perry et al., forthcoming) 133 reported total cases of transmission HIV: 2 surgeons-> 3 pts (0.09% pts infected) HBV: 12-> 91 pts (2.96% pts infected) HCV: 11-> 39 pts (0.36% pts. infected) HBV: Surgeon->pt transmission Most commonly when e antigen positive Many without evidence of injury to handsNOzOOzO  !Unanswered QuestionsAll cases but 1: surgeons transmitted One US surgeon transmitted HCV to at least 14 patients: Still operating What restrictions should exist for infected surgeons? Do we treat blood exposure of a patient = exposure to a HCW?Federal RegulationsOSHA mandates a sharps injury log No requirement to report to state or federal bodies State and regional reporting systems vary greatly>"42 SurveillanceExposure Prevention Information Network (EPINet) Dr. Janine Jagger (1991) UVa. International Health Care Worker Safety Center >1500 US hospitals; 70 facilities National Surveillance System for Health Care Workers (NaSH) CDC (1995) 80 facilities in 28 states N1o<'1o<'  P) ) California1996 Senate Bill Sharps Injury Control Program Voluntary reporting 90% of Hospitals report Weaknesses: No reporting of non-sharps injuries (ie mucocutaneous exposures) No sample of non hospital-based HCW sN8g8g  > ,Surveillance (ctd)Massachusetts Surveillance System for Sharps Injuries Mass. Dpt Public Health (2001) 100 hospitals; required by State Law VA Automated Safety Incident Surveillance (1998)N6D.6D.  <l Exposure Data in OR 33% (Highest proportion) of hospital-based percutaneous injuries (Epinet 2003) vs pt rooms, ER, clinics 16.5% (2nd) for hospital-based non-percutaneous injuries 1995-2001 (NaSH) Blood exposure events in 6-50% of surgical procedures (1997) Cuts or needle sticks 1.7-15%POO  b+  : ]Trends: OR lags in preventionR38% drop in injuries in patient rooms (all devices) only 5.7% drop in OR injuries2S2     OR PersonnelqSurgeons or 1st assistants (up to 59%) Scrub nurses/techs (19%) Anesthesiologists (6%) Circulating nurses (6%)j' c Exposure in ORSuture Needles cause the highest proportion of percutaneous injuries (up to 77%) From direct observational study (1992) Mostly in muscle and fascial closure Especially in using fingers to manipulate Scalpels more likely to cause serious injury :Qv.Qv.,/ RaTrends in Needle injuries<33% decline hollow bore needles 27% increase suture needles2=     Exposure in ORPassing instruments hand to hand (16%) Most self-inflicted But up to 24% by co-worker Non-dominant hand most common site Relatively few (<0.05%) are highest risk ie hollow bore needles Up to 1/3 devices come into contact with patient after HCW b;L<;L  <QPoor reportingSurgeons do not report up to 70% of injuries inconvenient to follow-up after a case not willing to stop a case assume exposure is  low-risk do not want to have serostatus known Rarely participate in post-exposure strategies:-/-/ 6 Exposure in ORGTypes of procedures High blood volume Poor visibility Length of timeh3hBloodborne Infections in Developing Countries (DC s)55( +9Concerning given global epidemics Lack of data 70% of global HIV cases are in Sub-Saharan Africa But only 4% of worldwide cases of occupational HIV infection from this region 4% of global HIV cases are in North America/Europe But 90% of worldwide cases of occupational HIV infection are reported from this regionVaZOZ3ZWZaO3W  8Needlestick Injuries in DC s 90% global surgical need in DC s WHO: 90% of needlestick injuries in DC s 35 million HCW s globally 3 million get a NSI each year 40% of HCV/HBV in HCW is from occupational exposure 2.5% of HIV&d^d^,- hBRisk factors for injuries in DC s7Prevalence of infections > 20 bloodborne pathogens (malaria/herpes/syphilis) Vaccine availability Low health expenditure and lack of devices High ratio of patients per HCW High Demand for injections 95% injections are therapeutic (not for vaccination) 80-90% pts visiting clinics in Ghana received an injection l4zp4zp   Developing Countries (ctd.)Uganda: HIV prevalence in Mulago Medical Wards 60%; Surgical 30% 2004 Mulago survey (nurses/midwives) 57% stick in last year; 4.18/person/year 55% (Mbarara) In 3 years of training 6/1000 clinicians would acquire HIV 10/1000 would acquire Hepatitis B|!  %NF! %  NF>'H_Effect on the health workforce6Ass. Surgeons East Africa (ASEA) Survey Deterrent to career choice in surgery Further exacerbates the shortage in health care workers with direct patient contact Attrition Alternative career choice Migration and brain drain We have the potential to share effective technologies with our partners UCSF and ACS (Z&ZTZ?ZHZZ(&T?  H%Epi Conclusions Suture needles cause the majority of injuries in the OR The OR lags far behind in prevention As surgeons we underreport injuries Risks to patients Risks to other members in OR Major problem for health care workers in the developing world  Thanks_Fellow contributors Dr. Janine Jagger at International Health Care Worker Safety Center (UVa)(J`,!4/8b7 ` flf3` 3f{FEɄ` OY?HsLp` nk3cR` Td4HV,{nR|:U^` N/qTʉ` ̙Ԝν@f` xfmR׍Ƴ~` [4>?" dd@,?lZd@  d lZ@ d`lZ n?" dd@   @@``PT $   @ ` `0p>> 11..n1(  B,T   "  c BlC DE F* @ y   l l y y @`" ~   c BC DE F*y @ [    [ [ @`"~   c BCDEF" @ @`"i (  c BCBDEF"@ B<0BB@`" ~:   0e0e     ?BCIDEF"  @ 5% 8c8c     ?1 d0u0@Ty2 NP'p<'p A)BCD|E||IMkII@`S"  BCeDEF" 0e00@`"v~   B]CDEF ]]] @`"#~    c B'C\DEF& @ \7\'*'\\@`"#   B CDEF"  @`"1   c B}CzDEF"d @ }~}z}~}~@`"~   BCDEF  @`"O ~?   c BCDEF"y @ HHH@`"U   c BC>DEF"d@ >86>>@`" ~'   c BCDEF" @ V@`"   c B[ C DEF"y @ I [ f@`"M   c BCC+DEF"yd @ C+CC+C+@`"; ~   BCODEF" O`ZOO@`"e ~k   c B2 Cx DEF"vy @  x 2  @`" v   BCDEF  @`" ~j   c B C DEF"y @  B@`"(     0e0e     ?BC DEF"  @ 5% 8c8c     ?1 d0u0@Ty2 NP'p<'p A)BCD|E||  =@`S" 6   c BTC`DEF"yd @ T`TZ T`T`@`"* ~   BCDEF" M@`"R~V  c B>CDEF" @ >S@`"0  c BUCDEF" @ U@`"#x  B<C8DEF" <8<6@`"B~  c BlCHDEF"y @ slHl*ss@`"Az   BCDEF  @`"z    c BlC9DEF"y @ nl9l3nn@`"hz    c BlCDEF" @ 0ll00@`"i z ! c B`Ci DEF"|y @ `i `Q }@`"zi  " c B| C6 DEF"y @ | 6 | 0 B@`" z6   # c BC DEF& @  @`"nz  $ c BCDEF"y @ *@`"z % c B"CDEF"y @ ""6@`"Vz & c BCDEF"y @ *@`"uz\ `~  ' "`~   ( c BKC!DEF& @ n3!?K@`"`V   ) c B9CDEF&d @ 9 H999@`"> ~  * 6p^ " ` 8 T Click to edit Master title style! !$ + 0a " ` 8 RClick to edit Master text styles Second level Third level Fourth level Fifth level!     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Sp;0 Ep 00(  x  c $ * `  8 x  c $!+ ` 8 H  0޽h ? 3380___PPT10.oQ+e"$ Pu(  X  C    8  S  0  8 w7Epi important b/c can be a guide for prevention efforts$ 'H  0޽h ? 3380___PPT10.aQPL"$ \(  X  C    8  S  0  8 ^0Consistent with data from Africa 2-4 sticks/year% H  0޽h ? 3380___PPT10.kQ=dxp^RЀ3ÿ lHbP  @AL G@;b `B&VJDZ|>AvAMyp"&  Oh+'0o hp    (4<'4Epidemiology of Perioperative Bloodborne InfectionshomeBeamMichael Lipnick112Microsoft PowerPoint@@Z#@E@c|8GnPICTn HH HH  l /4/4uWXY\]\YZ[UKJQ[\]^_`dkkfaXGHIUccdeZNZfnsggfehkhemp`Xjrprssttuvwvv]Ury^Yv{{||}UQTWXZ][YZ[XNJMX\]^_ ``cjkgaXHGGHIUde ZN[ffggxrhhgejlfe gqnY\qrssotuvyvwmUeykYl{|}UQQRUX[]^]ZYZ[SJKU\]^_`_`acjkha\IHIJTdeffZO]gizpiifefklelrfYgsqrtuvvxxww[VYzwZb||}UQRVXZ\]^[Z[\XMKO[]^_`abjkjc]JHIJSef [O]gghi{oiifeglmmke fpq]ZqstspuvwwywxjVpzd[z}UQSWXYY[]^][Z[\[QKLX]^_`acikjd_LHIJKSfgg[O_hhij|njjfeimnnhe jskYdttursuvwwxxyxwYWb{o\q}~UQUY\^__]Z[\]WLLT^_`_`abillebOIIJKSefgh\P`ik~mjjelnnmfepsbZpuquvvwxxyxyiXYx{^]h}~UQVYZ]^_\[\][PLO\^_`abchlkfbQJKLSfg hh]Q`ijjm~mkjefmnolfe htp\auuvstwxzyywZYn|i_a~UQRSWY[]^^_\[\]^ULNX^^_`abcfklgcTJJKLMMSeghii]Qbjn}mljehopokenuh[mvswxyy{zzgZb|taw~UQRTXYYZ]_]\[[\]^[OMT^_`_`abcdfklieXKLMNRfhi ]Scjkkp|mlifkphf gtt__uvwutxy{{zu\x|ecoUQRSUYZ]_`_]\]^]TMQ\_`abcddflmkf[KLMNSfij ^Sdkklr|nmifmpgflvn]kwtxxyz|{{g]m}pehUQRSWYZZ[^__`^\]^__ZOOX`abcdeflmkf_MLMNOOSeijk_Tflsznnhfoqqofsve_uxxwtyz{|{v_b~yh|UQRTXZ[[]_`aa`^\\]^_^RNT_abcdekmmgbOMMNOOPPTfjkkl_Uflmmtynnhfhqrrlfkwt_gxuxyz{{}||gawmjvUQRSSUY[^`a`^]^_`XOQ]abcdeffjnmhcPNOOPPQQTfjk ll`Vgmnnwwonhglrjgrwk`syyxvz{||}}ucmvmrUQRSW[]_`abb_]]^_`]QPYabcdefjnnifSOOPQQRRTeklmaWinywoohgnssrig jxwdfyyzwyz{|}}ief~}opUQRSTWZ\\^`aba_^_`_`aWPU`bbcdefgiookhWPQQRRSSUflm bWjnoo{vpnghqstqgoxqbqzw{{|}}~~ugvuq{UQRSTTUZ\^abcca^_`ab]RR]cdefginomhYPQQRRSSTTVelmmn bXjoop}tqngistungwyjeyz{xy|}~}kio{tyUQRSTVZ\\^`bc`_`ab`VRYbccdefghjoonj]QRRSSTTUUWemn od[kppq~trnhlukhnzwdn{w||}~uk~vwXTQRSTUX\]]^abcddc`_`_`abcc[SVadefghinpok`RSTUUVVWfn oopd\mpqrsrmhpuutihvzoex||z{}~~nmwzwYYXTQRSTUY]]^`bcdb`abc`VT^ddefghhijjnppldSTTUUVWWXXeno ppe]nqqssslhisvvrh k{{im||}y}}~vory~YZXTRQRSTUV[^^_`cdeeda`abcdc[TYdeefghijnqpmgU VWWXXYYepop qf_prrsttlijuwwpis{vhw}}|{~}rq~|{{|YYZYUQRSTUVX]^^_cdefdabcd`VW`fghij kknrqmhWVWXYZZ[epq g_prsuuskinwwxli jz|om}}~|~xsz~||~ZYURSTUVY^__adefecbcdeecZV_ffghhijklmqqokZXYZZ[[\epq rrhaqsswutkjqxxvkjr}zjv~}uv}}Z[ZVSRSTUVW[_bdefggecbcdeff_WZfghijkl nrspm]XYZZ[\]eqr sicrttxutkjuxytjy}un}~}yv~Z[ZWSRSTUVWWX]`dfghhfcdefdZYbhijkklmstqm`ZZ[\\]]^_frs jeruuy~vsjkxyyqjn~~pv~x{Z[\[YSRRSTUVWXZ_aabeghdccdefggf_Y_gijklmmnrtsod[\\]]^__`frs ttlftuvz}wsknzzynkx~zo|{yzZ[\YUSTUVWX\`aadgghiifdefghd[\fiijklmnorutqg\]]^_``aagrt uulguvv|}xrkrzzxkm~tvzZZ[\ZVSTUVWXZ]bbcehijifefghig_[cjkklmnooprvupi_^_``aabcgttu mhuww~|xqlv{{vl u~s|{}Z[\][WSTUVWXYYZ_bcdgijfefghhid\aijklmmnopprvvrk`_`aabcddhtuuv okvwx|yplmy||rlm}yw|}[\]^\XUTUVWXY\accehjkifghijjh__hklmnoopopqrvwtnbabbccdeeisv wwomwxx{zomp||}pmsw|}..A.XZZ[\]^]XUTUVWXYZZ^cddgjkllkighijkd^elmnoopqswxupdbcddeffgjuvw xpmwyz{xoms}}ynm|~y~~؁OO\AAUUVXZ\]^_^ZUVWXY|fiklmjggijkhacjmmnoppqrwyvqgddeffghhjvwwx roy|yonw}~xn q{} ͟yppOO\AO..\UWZ\]^_^[VUUVWXY.`egkllm|Xnnj\dijklkdain|XoopoppCqrsswzxsjeffghhijmvx yysqOL{ypo{~~toz{G@AAf.OOOA\f .£A?y\ҫf fAUVY[\]^_`_`_[VWXYESFF{ma\bkkgbp@sshiklmv}yoq~~qo pJױ@AOp.yf\OO‰ґf ‰yAAyyy.. .\UVX\]^_`a`]XVVWXYZǣ\ɌgӒ\kW܄uAӒbXq=lm݄7w}xpu|qpv~?@OOOґO\AOOOy} OAAAOyבAAOOyOטOґ.AApy. 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