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We investigated cases of acute hepatitis B in The Netherlands that were linked to the same general surgeon who was infected with hepatitis B virus (HBV).
A retrospective cohort study was conducted of 1,564 patients operated on by the surgeon. Patients were tested for serologic HBV markers. A case–control study was performed to identify risk factors.
The surgeon tested positive for hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) with a high viral load. He was a known nonresponder after HBV vaccination and had apparently been infected for more than 10 years. Forty-nine patients (3.1%) were positive for HBV markers. Transmission of HBV from the surgeon was confirmed in 8 patients, probable in 2, and possible in 18. In the remaining 21 patients, the surgeon was not implicated. Two patients had a chronic HBV infection. One case of secondary transmission from a patient to his wife was identified. HBV DNA sequences from the surgeon were completely identical to sequences from 7 of the 28 patients and from the case of secondary transmission. The duration of the operation and the occurrence of complications during or after surgery were identified as independent risk factors. Although the risk of HBV infection during high-risk procedures was 7 times higher than that during low-risk procedures, at least 8 (28.6%) of the 28 patients were infected during low-risk procedures.
Transmission of HBV from surgeons to patients at a low rate can remain unnoticed for a long period of time. Prevention requires a more stringent strategy for vaccination and testing of surgeons and optimization of infectious disease surveillance. Policies allowing HBV-infected surgeons to perform presumably low-risk procedures should be reconsidered.
To identify exposures associated with acute hepatitis B virus (HBV) infection among residents with diabetes in a skilled nursing facility.
Residents from Unit 3 and other skilled nursing facility residents with diabetes were tested for serologic evidence of HBV infection. Two retrospective cohort studies were conducted. Potential routes of HBV transmission were evaluated by statistical comparison of attack rates.
A 269-bed skilled nursing facility.
All skilled nursing facility residents with diabetes and skilled nursing facility residents who lived on the same unit as the index case (Unit 3) for some time during the case's incubation period.
All 5 residents with acute HBV infection had diabetes and resided in Unit 3. The attack rate among the 12 patients with diabetes in Unit 3 was 42%, compared with 0% among 43 patients without diabetes (relative risk, 37.2; 95% confidence interval, 4.7 to ∞). Acutely infected patients with diabetes received more morning insulin doses (P = .05), and more insulin doses (P = .03) and finger sticks (P = .02) on Wednesdays than did noninfected patients with diabetes. Two chronically infected patients with diabetes in Unit 3 were positive for hepatitis B e antigen and regularly received daily insulin and finger sticks. Of the 4 acute and 3 chronically infected residents from whom HBV DNA was amplified, all were genotype F and had an identical 678-bp S region sequence. Although no component of the lancets or injection devices was shared among residents, opportunities for HBV contamination of diabetes care supplies were identified.
Contamination of diabetes care supplies resulted in resident-to-resident transmission of HBV. In any setting in which diabetes care is performed, staff need to be educated regarding appropriate infection control practices.
To determine the seroprevalence and risk factors for hepatitis C virus (HCV) infection among patients at an urban outpatient hemodialysis center.
This was a cross-sectional study of 227 patients undergoing hemodialysis at the Rogosin Kidney Center on December 15, 1998, with a response rate of 90% (227 of 253). Laboratory records were used to retrieve the total number of blood transfusions received and serologic study results. Univariate and multivariate analyses were used to examine the relationship among HCV serostatus, patient demographics, and HCV risk factors (eg, intravenous drug use [IVDU], intranasal cocaine use, multiple sexual partners, comorbidities, length of time receiving hemodialysis, and total number of blood transfusions received).
The seroprevalence of antibody to HCV (anti-HCV) was 23.3% (53 of 227) in the population. In univariate analysis, factors associated with HCV seropositivity included male gender, younger age, history of IVDU, history of intranasal cocaine use, history of multiple sexual partners, human immunodeficiency virus coinfection, increased time receiving dialysis, history of renal transplant, and positive antibody to hepatitis B core antigen. Multivariate logistic regression analysis showed that longer duration receiving dialysis and a history of IVDU were the only risk factors that remained independently associated with HCV seropositivity.
HCV is markedly more common in our urban cohort of patients receiving hemodialysis compared with patients receiving dialysis nationally and is associated with a longer duration of receiving dialysis and a history of IVDU. Stricter and more frequent enforcement of universal precautions may be required in hemodialysis centers located in areas with a high prevalence of HCV infection or IVDU among the general population.
This study presents the results of a 5-year surveillance program involving the prospective follow-up of health-care workers (HCWs) in the Veneto region of Italy exposed to blood-borne viruses.
All HCWs who reported an occupational exposure to blood-borne infection joined the surveillance program. Both HCWs and patients were tested for viral markers (hepatitis B surface antigen [HBsAg], antibody to hepatitis B surface antigen [anti-HBs], antibody to hepatitis B core antigen [anti-HBc], antibody to hepatitis C virus [anti-HCV], HCV RNA, and antibody to human immunodeficiency virus [HIV]) and had these markers plus transaminases assayed at 3, 6, and 12 months and then yearly thereafter. Moreover, a program of hepatitis B virus (HBV) prophylaxis was offered to those whose anti-HBs levels were less than 10 IU/mL.
Two hundred forty-five HCWs (156 women and 89 men) with a mean age of 37 (± 10) years who reported occupational exposure during the 5-year period.
At the time of exposure, 1HCW was positive for HBsAg (0.4%) and 2 were positive for HCV RNA (0.8%). Among the patients involved, 28 (11.4%) were positive for HBsAg, 68 (27.8%) were positive for HCV RNA, 6 (2.4%) were positive for HIV, and 147 (60.0%) were negative for all viral markers (4 patients were positive for both HCV and HIV). During the follow-up period after exposure (mean, 2.7 [± 1.6] years), there was no increase in transaminases or seroconversions to any of the viral markers.
Our accurate postexposure follow-up revealed a lack of transmission of HBV, HCV, and HIV.
To identify the routes of transmission during an outbreak of infection with hepatitis C virus (HCV) genotype 2a/2c in a hemodialysis unit.
A matched case-control study was conducted to identify risk factors for HCV seroconversion. Direct observation and staff interviews were conducted to assess infection control practices. Molecular methods were used in a comparison of HCV infecting isolates from the case-patients and from patients infected with the 2a/2c genotype before admission to the unit.
A hemodialysis unit treating an average of 90 patients.
A case-patient was defined as a patient receiving hemodialysis with a seroconversion for HCV genotype 2a/2c between January 1994 and July 1997 who had received dialysis in the unit during the 3 months before the onset of disease. For each case-patient, 3 control-patients were randomly selected among all susceptible patients treated in the unit during the presumed contamination period of the case-patient.
HCV seroconversion was associated with the number of hemodialysis sessions undergone on a machine shared with (odds ratio [OR] per additional session, 1.3; 95% confidence interval [CI95], 0.9 to 1.8) or in the same room as (OR per additional session, 1.1; CI95, 1.0 to 1.2) a patient who was anti-HCV (genotype 2a/2c) positive. We observed several breaches in infection control procedures. Wetting of transducer protectors in the external pressure tubing sets with patient blood reflux was observed, leading to a potential contamination by blood of the pressure-sensing port of the machine, which is not accessible to routine disinfection. The molecular analysis of HCV infecting isolates identified among the case-patients revealed two groups of identical isolates similar to those of two patients infected before admission to the unit.
The results suggest patient-to-patient transmission of HCV by breaches in infection control practices and possible contamination of the machine. No additional cases have occurred since the reinforcement of infection control procedures and the use of a second transducer protector.
Occupational exposure to human immunodeficiency virus (HIV) is an important threat to healthcare workers. Centers for Disease Control and Prevention guidelines recommend prompt institution of prophylaxis. This requires (1) immediate prophylaxis after exposure, pending test results that may take more than 24 hours in many hospitals; or (2) performance of a rapid test. The Single Use Diagnostic System (SUDS)® HIV-1 Test is used to screen rapidly for antibodies to HIV type 1 in plasma or serum, with a reported sensitivity of more than 99.9%. We used this test from January 1999 until September 2000, when it was withdrawn from the market following reports claiming a high rate of false-positive results.
We reviewed the results of postexposure HIV testing during 21 months.
A total of 884 SUDS tests were performed on source patients after occupational exposures (883 negative results, 1 reactive result). The results of repeat SUDS testing on the reactive specimen were also reactive, but the results of enzyme immunoassay and Western blot testing were negative. A new specimen from the same patient showed a negative result on SUDS testing. This suggested a specificity of 99.9%. In the 4 months after SUDS testing was suspended, there was 1 false-positive result on enzyme immunoassay for 1 of 132 source patients (presumed specificity, 99.2%).
Use of the SUDS test facilitated rapid and accurate evaluation of source specimens, obviating unnecessary prophylaxis.
To describe nosocomial transmission of malaria from patient to patient via blood exposure.
A 56-year-old man was admitted to an Italian hospital with fever and Plasmodium falciparum parasitemia, but with no risk factors for malaria. Twenty days earlier, he had been admitted for bronchopulmonary disease to the hospital's intensive care unit, where a woman with P. falciparum malaria acquired abroad was present.
We reviewed both patients' medical records and searched for mosquitoes in the hospital and on the grounds. We interviewed the staff about patient care practices potentially involving contact with blood. The genetic identities of strains were determined by genotyping of the DNA extracted from blood.
Molecular genotyping showed that the two strains were identical. The only invasive procedures performed on both patients by the same staff on the same shift were capillary blood sampling by finger stick, intravenous drug administration, and substitution of total parenteral nutrition bags and intravenous sets. The flngerstick device used was designed to prevent person-to-person transmission of blood-borne infections, and the staff interviews did not reveal any incorrect use of aseptic techniques. The likely source of infection was identified during a training course 6 months later: a nurse reported that, when collecting blood, she placed patients' fingers directly on the blood glucose meter, a practice she had learned from a poster advertising the device.
A nosocomial case of malaria was ascertained, which was likely due to patient-to-patient transmission via a contaminated blood glucose meter. Incomplete instructions for the meter seem to have played a role in this case.
An episode of acute hepatitis in a patient with hemophilia during immunoadsorption therapy initially was misinterpreted as a reactivated hepatitis C virus (HCV) infection, but ultimately was shown to be an exogenous reinfection during cohort treatment with another HCV-positive patient. This incident illustrates that policies for the prevention of nosocomial transmission of blood-borne pathogens, especially in cohort treatment units, may need to be reassessed.
We describe a cluster of acute hepatitis A virus (HAV) infection that involved two patients and one physician in the pediatric unit where two children with acute HAV infection had been housed. An interview with the unit personnel revealed several breaches in infection control measures and the lack of vaccination of healthcare workers against HAV.
We documented a case of occupational human immunodeficiency virus (HIV) despite postexposure prophylaxis (PEP) with a combination drug regimen after percutaneous injury with a needle from a sharps disposal container in the hospital room of an HIV-infected patient. This failure of PEP with a combination drug regimen may have been related to antiretroviral drug resistance, other factors, or both. This case highlights the importance of preventing injury to prevent occupational transmission of HIV.