|Year : 2005 | Volume
| Issue : 2 | Page : 75-80
|Orthopaedic trauma surgeon and HIV
RK Sen, JA Satpathy, Sameer Aggarwal, ON Nagi
Department of Orthopaedic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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|How to cite this article:|
Sen R K, Satpathy J A, Aggarwal S, Nagi O N. Orthopaedic trauma surgeon and HIV. Indian J Orthop 2005;39:75-80
India is experiencing a rapid and extensive spread of HIV. This is particularly worrisome since India has more people than the continents of Africa, Australia and Latin America combined. In 1996 it was estimated that there were 2 to 5 million people infected with HIV and 50,000 to 1,00,000 cases of AIDS may have already occurred  . An estimate in 2001 has shown that, India is the country with the second largest population of HIV-infected individuals , . A current estimate of HIV infection among adult population between 15-49 years of age is 0.7% ,. Contrary to traditional belief, sexually transmitted diseases and sex with multiple partners are not uncommon in the country, both in urban and rural areas. Out of the two major types of HIV in humans, HIV type 1 and type 2, presence of both has been reported from India. There have been very few investigations of HIV-1 strain variation in India. Available data indicates that subtype C is most predominant in India. Subtypes A, B and E also co-exists. The C3 genotype may be a recent mutational variant of subtype C unique to India ,.
Prevalence of HIV
HIV is rapidly spreading to rural areas through migrant workers and truck drivers. One survey  shows that 5-10% of some truck drivers in the country are already infected with HIV. Such mobile population is also at the highest risk of motor vehicle accidents so common in our country. These accident victims in our emergency out patient department usually remain unrecognized for their HIV status, as more than half of HIV-positive patients are likely to have no sign or symptom of the disease  . In a study  , sero-prevalence of HIV was found to be 5.2% among the general emergency department population, with a 5% rate in patients with unknown or unrecognized HIV infection. It can be speculated that the HIV infection among patients refusing the test and among those who present to emergency room at night with open wounds may still be higher. In the study 4% of patients presenting to the adult emergency department who had blood drawn and whose HIV status was unknown at the time of their visit were found to have unrecognized HIV infection  . The infection rate among those with critical illness or injury appeared to more than double to 7.8% during one year interval  . Chamberland et al has shown high HIV seroprevalence in surgical patients in an emergency set up [Table - 1] .
Occupational exposure of HIV
The risk of HIV infection in surgical settings is a composite of overlapping risks related to the local prevalence of HIV, the route of exposure and the susceptibility of worker. Faster increase in HIV positive population in India is making all orthopaedic surgeons especially those doing trauma surgeries more prone for occupational hazard of HIV.
Occupational infection with HIV is not only a medical problem; it is a personal tragedy in physical, psychological, social, professional and financial terms. The occupational transmission of this pathogen from patients to health care worker has been well documented  . HIV is transmitted by blood and certain other body fluids. Surgeons have numerous chances for occupational blood exposures, so are at higher risk of infection with these blood borne pathogens because of their frequent use of sharp instruments and objects starting from the emergency to the ward and than in operation theatres [Table - 2].
Exposure at emergency level
In Hospital emergency department, when a patient having open injuries and with poly-trauma is examined many exposure prone procedures are performed without adequate precautions. Marcus et al  have estimated the annual risk of HIV infection for a full time emergency department physician or nurse practicing the observed level of glove use with high and low HIV prevalence populations as ranging from 0.0265 to 0.008% and 0.002% to 0.0005%.
The study through questionnaire by Van Rijssen and FJ Nijhuis  among Dutch general and orthopaedic surgeons showed that relatively small number of the respondents actually used protective cover; 83% of emergency department respondents did not use safety glasses. Though there was availability of barrier protective materials in emergency departments, this availability did not imply the use of these devices. It was explained to be due to difficulty and time consumption in putting on protective gear and the potential of barrier protective materials in further interfering with procedural skills.
Exposure in operation theatre
Between 6% and 50% of surgeries involved one or more blood contacts ,,. Wright et al  in his study has shown that the risk of blood contact was greater for surgeons when patient blood loss was greater than 250mL, when the surgeon had been in the operating room longer than 1 hour, and during emergency procedures in the trauma, burn, or orthopedic service. Skin contact, including garment soakage, was the type of contact most frequently observed and is probably associated with the least risk of infection transmission. Members of the operating room can be exposed to a patient's blood as a result of injury with suture needles, sharp instruments or other sharp object's such as wires or bone spicules. Percutaneous and skin exposure to patient's blood occurs quite frequently. The risk of exposure is correlated with the type of operation, blood loss, emergency procedure, use of fingers rather than instruments to hold tissues being sutured, length of operation and time of the procedure. Tokars et al  in their study have shown the common modes of percutaneous injury during a surgery [Table - 3].
Among surgeons, trauma surgeons are particularly at risk. Orthopedic surgeon during trauma surgery have to do lot of washing of open wounds and debridement. Tokars et al  have reported two of 3,420 orthopedic surgeons having HIV positivity; however both had other risk factors. Study by Panlilio et al  showed that among health care workers, surgeons particularly orthopaedic trauma surgeons & gynecologists are at more risk of getting HIV infection [Table - 4]
Risk of sero-conversion after exposure
Study of Wright et al  showed that although the risk of sero-conversion after a single exposure is relatively low, the risk for surgeons is more appropriately expressed as a cumulative lifetime risk. The estimated cumulative risk of HIV sero-conversion for surgeons may be as high as 1 to 4%. Chou et al  have quoted a life time risk of 30% or more, using the highest reported number for each variable.
Chamberland et al  showed the average risk of seroconversion after a needle stick injury has been found to be approximately 0.3% and nearly all of sero-conversion after a percutaneous injury occurred due to injury with a hollow bore needle. Similarly sero-conversion following mucus membrane exposure has been estimated to be 0.09%  .Seroconversion following cutaneous contact with blood has not been recorded in any of the prospective studies of date  .
The likelihood of sero-conversion following a percutaneous injury involving blood from an HIV infected patient appears to be affected by overlapping factor related to the circumstances of injury, infectiousness of the source of patient, the susceptibility of health care worker (HCW).
Steps in preventing the risk of transmission of HIV
Pre operative screening
Preoperative screening is not cost effective and precautions should be applied to every surgical procedure, not selectively for patients known or suspected to be HIV positive. The Centers for Disease Control and Prevention (CDC)  however recommends routine screening for HIV, with informed consent, for patients between 15 and 54 years of age in regions of high HIV prevalence  .
Precautions at the emergency and ward level
- Consider sharp items (needles, scalpel blades) potentially infective and handle these with extra ordinary care to prevent accidental injuries.
- Place disposable syringes and needles, scalpel blades and other sharp items in puncture - - resistant containers located as near as is practical to the area in which they were used. Needles should not be recapped, purposely bent, broken, removed from disposable syringes or otherwise.
- All health care workers should wear protective barriers (gloves, gowns, masks and protective eyewear) to prevent exposure to blood, body fluids containing visible blood and other fluids to which universal precautions apply. Gloves should be changed after contact with each patient. Gowns or aprons should be worn during procedures that are likely to produce splashes of blood or other body fluids.
- Immediately and thoroughly wash hands and other skin surfaces that are contaminated with blood, body fluids containing visible blood, or other body fluid to which universal precautions apply.
- Although saliva has not been implicated in HIV transmission, to minimize the need for emergency mouthto-mouth resuscitation, mouthpieces, and resuscitation bags or other ventilation devices should be easily available for use in area where the need for resuscitation is predictable.
- Clean spills of blood or other body fluids should be washed with soap and water. Freshly prepared solutions of sodium hypochlorite in concntration of 1:10 dilution is effective disinfectant.
- Health care workers who have exudative lesions or weeping dermatitis should refrain from all direct patient care and from handling patient care equipment until condition resolves.
In the operation theatre
- All personnel must be thoroughly knowledgeable of universal precautions and proper methods to minimize the risk of blood exposure.
- Limit all surgeries to essential personnel.
- Restrict personnel with open wounds.
- Do not lean on the operative field.
- If patient is known HIV positive, restrict nurses and medical students.
- Hand protection: To wear double gloves, particularly puncture resistant gloves. Study of Bennett et al  and Mast et al  have shown that one layer of surgical gloves appears to decrease the volume of blood injected by solid suture needles by 70% and a second layer a further reduction of 50% or more. The surgeon should look at the gloves frequently to assess integrity.
- Skin protection: Use of inner plastic gowns to prevent soakage of gown leading to blood skin contact. Double sleeves should be worn if forearms are likely to be contaminated. Gown with heavy contamination should be changed. Tyler et al  have reported that least protective gowns were made of cotton and has fluid soakthrough with pressure as low as one cm of H 2 O. A small splash of blood has ~5-10cm of H 2 O pressure, where as impact of surgeon leaning against a wet surface is roughly 50 cm of H2 O. They documented that four of the gowns tested had HIV penetration. In use tests have showed that even with most impermeable gowns, those reinforced with plastic still sheared if worn for longer than 3-4 hr.
- Face protection: Use of high efficiency masks, use of protective eye shields, face shields, helmets and full head cover particularly in high risk cases.
- Avoid blind digital palpation of sharp body ends or implants in deeper cavities.
- Hand free technique should be used i.e. the surgeon and the surgical nurse do not touch the same instrument at the same time. This is achieved by placing the sharp instrument in so-called neutral zone that is cleared of other instruments. Reduce the risk of scalpel and other sharp injury by using round tipped blades, disposable scalpels, and retractable blades. Announce passage of scalpels and other sharp instruments.
- No touch technique: The use of extension such as sponge force rather than hands, to handle or touch contaminated items or handle or touch sterile items. While suturing, needle should never be held in fingers. Assistant should keep his/ her hand off the table and from the person suturing.
- Simultaneous suturing by two surgeons should be avoided.
- Surgical nurse should take all the sharp instruments of the operating table when it is not in use.
Steps to be taken after accidental exposure:
- Provide immediate care to the site
- - Wash wounds and skin with soap and water immediately.
- - Bleed the wound; apply 70% isopropyl alcohol on the wound directly.
- - Flush mucus membranes with water.
- - Report the incident to the health care facilities (HCF) or concerned authorities.
- Determine the risk associated with the exposure
- - Type of fluid
- - Type of exposure
- Evaluate exposure source
- - Assess the risk of infection using available information
- - Test the source for HIV antibody after taking informed consent.
- Give post-exposure prophylaxis for exposures posing risk of infection transmission.
a) Ziduvudine 600mg/day in 2-3 divided dose along with Lamivudine 150mg twice daily
b) Lamivudine + Stavudine 40mg twice daily
c) Diadanosine 400 mg daily + Stavudine 40mg twice daily
- Perform follow up testing and provide counseling
- - Advise exposed persons to seek medical evaluation for any acute illness occurring during follow-up.
- - Perform HIV - antibody testing
For at least 6-month post exposure, the routine method for anti body detection is ELISA. Two positive tests require confirmation by another technique, usually the Western Blot Test. ELISA being an antibody test becomes positive only after 6 weeks to 6 months.
Diagnosis during this window period is very important.
- - p24 ELISA can detect infection as early as two weeks after infection depending upon quantum of exposure.
- - DNA-PCR can detect positivity as early as 48-72 hours after the exposure. Generally one week after the suspected exposure is the right time to test with DNA-PCR.
- - Perform HIV antibody testing if illness compatible with an acute retroviral syndrome occurs.
- - Advise exposed persons to use precautions to prevent secondary transmission during the follow up period.
- - Evaluate exposed persons taking post exposure prophylaxis (PEP) within 72 hours after exposure and monitor for drug toxicity for at least 2 weeks.
Practice recommendation for hospitals
- Establish a blood borne pathogen policy
--All institutions where health care personnel might get HIV exposure should have a written policy for management of exposures
- Implement management policies
--Health care facilities (HCF) should provide appropriate training to all personnel on the prevention of and response to occupational exposures
- - HCF should establish exposure reporting systems
- - HCF should have a personnel who can manage an exposure, readily available at all hours of the day
- - HCF should have ready access to post exposure prophylaxis for use by exposed personnel as necessary.
- Establish laboratory capacity for blood borne pathogen testing
--HCF should provide prompt processing of exposed person and source person specimens to guide management of occupational exposures.
- Select and use appropriate PEP regimen.
--HCF should develop a policy for the selection and use of PEP antiretroviral regimens for HIV exposures within their institution.
- - HCF should have access to resources with expertise in selection and use of PEP
- Provide access to counseling for exposed health care personnel (HCP)
- - HCF should provide counseling for HCP who might need help dealing with emotional effect of an exposure
- - HCF should provide medication adherence counseling to assist HCP in completing HIV PEP as necessary
- Monitor for adverse effects of Post exposure prophylaxis
- - HCP taking antiretroviral PEP should be monitored periodically for adverse effects of PEP through baseline testing and clinical evaluation
- Monitor for sero-conversion
- - HCF should develop system to encourage exposed HCP to return for follow - - up testing.
In conclusion the infection with blood borne pathogens has long been recognized as an occupational risk for health care workers especially orthopaedic surgeons. The emergence and spread of HIV provide a new threat to surgeons and other health -care workers exposed to the risk of occupational infection and sero-conversion. In an Indian setup, the risk of transmission and cost effectiveness of protective wears hospital engineering controls has to be balanced. In such a situation, until vaccination becomes available, protection against HIV transmission is important. Systematic testing of patients before operation is still getting effective. In these circumstances simple work practices and guidelines as mentioned will help in reducing the transmission of HIV to orthopaedic surgeons.
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O N Nagi
H No 1027,24-B, Chandigarh-160023
Source of Support: None, Conflict of Interest: None
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]
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