APIC position paper: hepatitis C exposure in the health care setting. Association for Professionals in Infection Control and Epidemiology, Inc

The Association for Professionals in Infection Control and Epidemiology, Inc (APIC), is a multidisciplinary, voluntary, international organization of professionals who practice infection control and the application of epidemiology in all health settings. APIC is an international leader in prevention and control of infection transmission.     

Long-term peritoneal dialysis before transplantation and intra-abdominal infection after simultaneous pancreas-kidney transplantations

OBJECTIVE: To examine the attitudes and knowledge of health care professionals regarding human immunodeficiency virus (HIV) infection in countries with a varying prevalence of HIV infection to assist in the development of acquired immunodeficiency syndrome (AIDS) educational programs. DESIGN: Anonymous questionnaire with four sections: demographics, attitudes, knowledge, and an open-ended question investigating feelings about the potential impact that HIV infection may have on respondents' practices. PARTICIPANTS: Final-year medical students, house staff, and attending physicians at teaching hospitals in India, Thailand, Canada, and the United States. RESULTS: From January to October 1992, 819 health care professionals completed the questionnaire: 340 from India, 196 from Canada, 155 from the United States, and 128 from Thailand. The percentage of respondents who had previous contact with patients with HIV/AIDS varied from 30% to 98%; it was lowest in India, followed by Thailand and then Canada, and highest in the United States. Percentages of respondents uncomfortable performing a physical examination on a patient with HIV/AIDS were 24%, 25%, 9%, and 4%, respectively. Mean HIV/AIDS knowledge scores were 83%, 84%, 92%, and 93%, respectively. Most respondents correctly identified modes of transmission of HIV infection. Only 67% of Indian health care professionals understood the concept of a false-negative screening serologic test, compared with 98% of Canadian health care professionals. In Canada and the United States, only 78% and 76%, respectively, understood the concept of a false-positive screening serologic test. Awareness of an asymptomatic stage of HIV infection ranged from 32% in India to 74% in Canada. Despite their concerns of becoming infected, health care professionals in countries with a lower prevalence of HIV infection reported a strong ethical duty to care for these patients. CONCLUSIONS: Level of comfort in caring for HIV-infected patients and HIV/AIDS knowledge scores varied directly with the amount of previous contact with these patients. Disturbing numbers of health care professionals from all four countries did not understand the potential problems of the enzyme-linked immunosorbent assay serologic test and a significant percentage were unaware of the asymptomatic stage of HIV infection. There is a universal need for increased education of health care professionals about HIV infection and AIDS.     

Extraction treatment of a Class II, Division 1 malocclusion with anterior open bite with headgear and vertical elastics

Needlestick injuries, which lead to the transmission of hepatitis B, hepatitis C, and the AIDS virus, are a potentially serious threat to students during their clinical experiences. Exposure to infectious diseases, blood, and hazardous body fluids is one of the most frequently reported injury events by medical students at a health science center in the southwestern region of the United States. This study was conducted to determine the effectiveness of a customized intervention about infection control for second-year medical students (N = 200). Preparation for the intervention included a needs assessment, which included both qualitative and quantitative research methods that incorporated input from fourth-year medical students, medical staff members, and local hospital infection control specialists. The intervention included a pretest, a lecture, a demonstration of standard precautions and infection control procedure with 2 clinical scenarios, an exercise on proper handwashing, and a posttest. The evaluation of the intervention demonstrated a significant increase in posttest knowledge scores about infection control (from 12.6 +/- 2.1 pretest to 16.5 +/- 1.8 posttest, P < .001). Medical students showed a significant knowledge increase about infection control after participating in the intervention . Thus we recommend that all medical colleges and universities develop and evaluate a similar customized intervention for their medical students.     

Identification of quantitative trait loci governing arthritis severity and humoral responses in the murine model of Lyme disease

A spectrum of disease severity has been observed in patients with Lyme disease, with approximately 60% of untreated individuals developing arthritis. The murine model of Lyme disease has provided strong evidence that the genetic composition of the host influences the severity of arthritis following infection with Borrelia burgdorferi: infected C3H mice develop severe arthritis while infected C57BL/6N mice develop mild arthritis. Regions of the mouse genome controlling arthritis severity and humoral responses during B. burgdorferi infection were identified in the F2 intercross generation of C3H/HeNCr and C57BL/6NCr mice. Rear ankle swelling measurements identified quantitative trait loci (QTL) on chromosomes 4 and 5, while histopathological scoring identified QTL on a unique region of chromosome 5 and on chromosome 11. The identification of QTL unique for ankle swelling or histopathological severity suggests that processes under distinct genetic control are responsible for these two manifestations of Lyme arthritis. Additional QTL that control the levels of circulating Igs induced by B. burgdorferi infection were identified on chromosomes 6, 9, 11, 12, and 17. Interestingly, the magnitude of the humoral response was not correlated with the severity of arthritis in infected F2 mice. This work defines several genetic loci that regulate either the severity of arthritis or the magnitude of humoral responses to B. burgdorferi infection in mice, with implications toward understanding the host-pathogen interactions involved in disease development.     

Hepatitis C: Part I. Routine serologic testing and diagnosis

Hepatitis C, which is caused by the hepatitis C virus (HCV), is a major public health problem in the United States. HCV is most efficiently transmitted through large or repeated percutaneous exposures to blood. Most patients with acute HCV infection develop persistent infection, and 70 percent of patients develop chronic hepatitis. HCV-associated chronic liver disease results in 8,000 to 10,000 deaths per year, and the annual costs of acute and chronic hepatitis C exceed $600 million. An estimated 3.9 million Americans are currently infected with HCV, but most of these persons are asymptomatic and do not know they are infected. To identify them, primary health care professionals should obtain a history of high-risk practices associated with the transmission of HCV and other bloodborne pathogens from all patients. Routine testing is currently recommended only in patients who are most likely to be infected with HCV.     

What do survivors of congenital diaphragmatic hernia look like when they grow up?

Health professionals in rural and remote areas of Australia are disadvantaged when accessing continuing education. Their geographical isolation influences attendance at seminars, workshops and even informal discussions with colleagues. This paper describes the strategies adopted to meet the continuing education needs of a group of health professionals working in diabetes education and discusses how other specialist areas can provide similar educational opportunities. The education programs for isolated health professionals involved in diabetes care in South Australia were created by a team, and the resources of their associated institutions. Formal working agreements were established to achieve the aim of relevant continuing education for rural health professionals and to ensure ongoing ventures. All programs have been positively received, and evaluations identify the need to develop other, related subjects. Future developments will further utilise advances in technology to extend access and add to the current modes of education delivery. It is the intention of this group to continue to develop practice-based subjects capable of meeting rural health practitioners' needs and thus enhance the quality of care in rural and remote communities.     

Forum: trauma and infection: considerations for patient and health care professional

Trauma and infection are leading causes of morbidity, mortality and health care expenditures despite remarkable advances in treatment over the past two decades. Numerous research studies report that in those trauma patients who survive the initial injury, infections account for over one-third of the deaths. While the immediate resuscitation of trauma patients is based on the principles of management for restoring airway, breathing, and circulation, long-term survival requires prevention of infection. Additionally, infection of the health care professional has long been known as a possible complication of caring for acutely ill and injured patients. This article reviews the risk of infection, the pathogenesis of infection, prevention, antimicrobial therapy and infection control for health care professionals.     

HIV-1 seroconversion in a prospective study of female sex workers in northern Thailand: continued high incidence among brothel-based women

OBJECTIVES: To determine the incidence of HIV-1 infection, temporal trends in incidence, and risk factors for seroconversion in a cohort of female commercial sex workers (CSW) in upper northern Thailand, the region of Thailand with the highest rates of HIV-1 infection. METHODS: CSW were enrolled from 1991 through 1994 and evaluated prospectively with interviews, physical examination, testing for sexually transmitted diseases (STD), and serologic testing for HIV-1 infection. RESULTS: The incidence of HIV-1 seroconversion in the first year of follow-up was 20.3 per 100 person-years among 126 brothel-based CSW and 0.7 per 100 person-years among 159 other CSW who worked in other venues such as bars or massage parlors. Incidence remained elevated among brothel-based CSW who were enrolled later in the study compared with those who enrolled earlier. Through 1996, 30 women seroconverted. In a multivariable proportional hazards model, seroconversion was significantly associated (P < 0.05) with brothel-based sex work (adjusted risk ratio, 7.3) and Chlamydia trachomatis cervical infection (adjusted risk ratio, 3.3). CONCLUSION: Despite national HIV control efforts and declining rates of infection among young men in Thailand, brothel-based CSW may continue to be at high risk for HIV-1 infection. Additional efforts are needed to provide alternative economic choices for young women, to ensure universal condom use during commercial sex, and to develop new prevention technologies.     

Be alert to an avoidable problem. Management and prevention of antibiotic-acquired diarrhoea

Antibiotic-associated diarrhoea is an unpleasant and distressing problem for patients and health professionals alike. Although this condition can be treated with drugs, patient relapses are common. Implementation of rigorous infection control policies are therefore required.     

Infection control and related issues in intravascular therapy

The use of Intravascular (i.v.) catheters has become an increasingly common practice in today's healthcare setting. This increase, however, brings associated problems. An overview of the current literature surrounding i.v. devices and infection control issues was undertaken. This included: the pathogenesis of infection with reference to local and systemic complications; the importance of handwashing; the influence of catheter material and type on infection rates; the controversy over skin preparation and whether it is best to use povidone-iodine, chlorhexidine or an antibiotic ointment; insertion techniques; the duration of line placement; the dilemma over the choice of dressing, i.e. gauze vs transparent; nurses' responsibilities in relation to the UKCC standards and professional accountability; safety issues; and the main principles surrounding the safe disposal of sharps. To conclude, this overview finds that all healthcare professionals must be held accountable for every aspect of i.v. therapy, including the control of infection.     

Exposure workups

Exposure workups are an important responsibility for infection control personnel. A well-designed plan for investigating exposures, which includes appropriate algorithms, will enable infection control personnel to evaluate exposures rapidly and consistently so that nosocomial transmission is minimized. Infection control personnel should use their own data to develop policies and procedures that suit the needs of their facility. After they have implemented the plan, infection control personnel should continue to collect data on exposures so they can continuously improve their performance.     

Gastric metaplasia of regenerating duodenal mucosa and deformity of duodenal bulb: a correlative study

Women's opinion on the maternal serum screening programme offered at one maternity unit in East Northumberland (1991-1992) was evaluated. The responses from 1,774/2,633 women showed a general acceptance of the test but 722/1,774 (40%) wanted more information and a third, more explanation. Recommendations, which included a 'gold standard' protocol, a video to complement revised patient information literature and a coordinator to facilitate interdisciplinary communication and training with support for midwives, were introduced. The audit cycle was completed by a repeat questionnaire survey of 2,489 women from the postnatal ward (1992-1994) with a 67.3% response. An overall improvement in levels of satisfaction with reduction in, but not eradication of, the need for more information and explanation had occurred. These findings have relevance to the current controversy surrounding the counselling implications of maternal serum screening and have led to the formation of a network of professionals to develop the programme in our region.     

General and oral manifestations of human immunodeficiency virus infection: a general overview with guidelines for infection control in the dental practice

The human immunodeficiency virus (HIV-1), responsible for the acquired immunodeficiency syndrome, has in the span of a decade become an epidemic of global proportions. Oral lesions, head and neck diseases are often the first manifestations of HIV-1 infection and AIDS. It is essential for all dentists to familiarize themselves with the oral manifestations of HIV-infection as well as the dental management of such manifestations. In addition to all health care, professionals should become acquainted with the "universal precautions" recommended by the Centers for Disease Control, in order to protect themselves, their staff, and their patients to minimize, if not totally eliminate, any risk of infectious disease transmission in the health care setting. This paper presents a general overview of the human immunodeficiency virus; oral manifestations of HIV-infection; "universal precautions" and guidelines for the control of infection in the dental practice.     

Class II major histocompatibility complex-deficient mice initially control an infection with Leishmania major but succumb to the disease

Class II major histocompatibility complex (MHC)-deficient (H-2b) mice do not express I-A or I-E molecules and, as a result, do not develop CD4 cells. Thus, they represent the ideal model for examining the importance of CD4 cells and MHC class II molecules in resistance to infection with Leishmania major and the capacity of MHC class I-restricted T cells to mediate resistance to L. major. Class II MHC-deficient mice and control (C57BL/6, normal and nude) mice were infected with L. major. Although MHC class II-deficient mice were able to control infection more effectively than nude mice, cutaneous lesions on the mice eventually progressed, and parasite replication became uncontrolled. These results suggest that CD4 cells and MHC class II molecules are essential for resistance to L. major and that in the absence of these cells and molecules, such mice can transiently control infection with L. major but are unable to resolve such infections.     

Astrocytic pathology in progressive supranuclear palsy: significance for neuropathological diagnosis

It has been shown that hepatitis C virus (HCV) infection is closely associated with mixed type cryoglobulinaemia. It is also known that HCV infection is rampant among chronic haemodialysis patients. We studied 531 renal failure patients on maintenance dialysis including 170 with positive HCV antibodies for cryoglobulinaemia, and its incidence was compared with controls which consisted of 242 chronic hepatitis C patients without renal failure and 183 healthy adults. Cryoglobulinaemia was present in 30.6% of dialysis patients with HCV infection, 10.8% of dialysis patients without HCV infection, 29.8% of patients with chronic hepatitis C without renal failure, and 0% of healthy adults. Among the 30 new renal failure patients who were started on dialysis within 6 months, four were positive for HCV antibodies, and one of them had cryoglobulinaemia; of the 26 HCV-negative patients, four (15%) were cryoglobulinaemic. The cryocrit values among dialysis patients were much lower than those of the control cases and other reports on non-dialysis cases. Patients with cryoglobulinaemia were generally younger compared with patients negative for this condition. There was no correlation between cryoglobulinaemia and past blood transfusion, underlying disease or length of dialysis. Cryoglobulinaemic patients seem to develop renal failure at relatively young ages and a considerable proportion of cryoglobulinaemic dialysis patients may have already had cryoglobulinaemia at the time of the start of haemodialysis. There was no indication that the presence of cryoglobulin in serum adversely affects the liver disease nor increases serum virus load in HCV-infected dialysis patients. Thus, it was concluded that although HCV infection has a certain role in the development of cryoglobulinaemia in dialysis patients, they develop cryoglobulinaemia less frequently and produce cryoglobulin to a lesser degree in the presence of HCV infection as compared with non-dialysis patients.     

Predicting Cost Deviation in Reconstruction Projects: Artificial Neural Networks versus Regression

This paper investigates the challenging environment of reconstruction projects and describes the development of a predictive model of cost deviation in such high-risk projects. Based on a survey of construction professionals, information was obtained on the reasons behind cost overruns and poor quality from 50 reconstruction projects. For each project, the specific techniques used for project control were reported along with the actual cost deviation from planned values. Two indicators of cost deviation are used in this study: cost overrun to the owner, and the cost of rework to the contractor. Based on the information obtained, 36 factors were identified as having direct impact on the cost performance of reconstruction projects. Two techniques were then used to develop models for predicting cost deviation: statistical analysis, and artificial neural networks (ANNs). While both models had similar accuracy, the ANN model is more sensitive to a larger number of variables. Overall, this study contributes to a better understanding of the reasons for cost deviation in reconstruction projects and provides a decision support tool to quantify that deviation.     

Results of a control programme for the porcine reproductive and respiratory syndrome in the French 'Pays de la Loire' region

The porcine reproductive and respiratory syndrome (PRRS) virus first entered the Pays de la Loire region in November 1992, with variable effects ranging from sub-clinical seroconversion to severe reproductive failure and piglet mortality, and significant reduction of daily weight gains in finishing pigs. An epidemiological survey was carried out in February 1993. Since the infection prevalence was low (11 infected out of 2310 herds), the pig population was of medium density and the eradication programme of Aujeszky's disease had been successful in the Pays de la Loire region, it was decided (in March 1993) to undertake a control programme for PRRS. In 1993, introduction of infected pigs was known to be the most frequent source by which PRRS virus entered a herd. In the absence of vaccination, this source of virus introduction was reduced by a control programme applied to all members of the regional pig industry, through the impetus of the leaders of the Regional Sanitary Defence Confederation (FRGDS). The control programme was applied on purchased animals (sows, boars, piglets), artificial insemination centres and other environmental factors (people, vehicles, materials, slurry,...). Moreover, pigs from many infected herds were slaughtered. Results showed that in a context of low prevalence and limited spreading to nearby herds, efficient control of animal movements limited the infection spread. At the end of 1993, the PRRS prevalence was 2.7% in the region. Two years after the first outbreak, the PRRS infection could be considered as controlled since 98% of the herds remained free. In order to maintain this low infected status, the control programme was renewed. From this study epidemiological investigations have raised two major initial sources of infection, the use of contaminated semen and the introduction of infected pigs. Around an infected herd, serological screening is still running to detect infection in nearby herds.     

Operationalizing the International Classification of Functioning, Disability and Health in Clinical Settings.

Functional status may be a better indicator of health care needs and outcomes than diagnosis. Appropriate use of the International Classification of Functioning, Disability and Health (ICF) in health service settings can provide a standardized way for clinicians to communicate complex clinical assessments to other professionals, administrators, and payers. The American Psychological Association is working with the World Health Organization to develop a Procedural Manual and Guide for a Standardized Application of the ICF for use by multidisciplinary health professionals. The Procedural Manual includes operational definitions of concepts, examples of each code, and assessment information relevant to each qualifier. The purpose of the Procedural Manual is to provide health professionals with the guidance necessary for reliable, valid, and clinically useful classification. This article discusses a range of issues and problems in the application of individual ICF codes in the context of health care and offers some potential solutions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An outbreak of Burkholderia (formerly Pseudomonas) cepacia respiratory tract colonization and infection associated with nebulized albuterol therapy

OBJECTIVE: To investigate an outbreak of Burkholderia (formerly Pseudomonas) cepacia respiratory tract colonization and infection in mechanically ventilated patients. DESIGN: A retrospective case-control and bacteriologic study. SETTING: Veterans Affairs medical center. PATIENTS: 42 mechanically ventilated patients who developed respiratory tract colonization or infection with B. cepacia and 135 ventilator-dependent controls who were not colonized and did not develop infections. MEASUREMENTS: Clinical and demographic data; benzalkonium chloride concentrations and pH levels in albuterol sulfate solutions; repetitive-element polymerase chain reaction (PCR)-mediated molecular fingerprinting on eight patient isolates and three environmental B. cepacia isolates that were available for study. RESULTS: 42 patients had B. cepacia respiratory tract colonization or infection. Observation of intensive care unit and respiratory care personnel showed faulty infection control procedures (for example, the same multiple-dose bottle of albuterol was used for many mechanically ventilated patients). More case patients (39 [92.9%]) than controls (95 [70.4%]; P = 0.006) received nebulized albuterol, and case patients (67.5 treatments) received more treatments than controls (18 treatments; P < 0.001). In-use albuterol solutions had pH values that were unstable, and benzalkonium chloride concentrations declined over time to levels capable of supporting bacterial growth. Medication nebulizers and in-use bottles of albuterol harbored B. cepacia. Molecular fingerprints of patient isolates and environmental B. cepacia isolates were identical using repetitive-element PCR. No further isolates of B. cepacia were identified after institution of appropriate infection control procedures. CONCLUSIONS: Multiple-dose medications and reliance on benzalkonium chloride as a medication preservative provide a mechanism for nosocomial spread of microorganisms, particularly if infection control procedures are not carefully followed. Repetitive-element PCR is a useful fingerprinting technique for molecular epidemiologic studies of B. cepacia.     

Co-ordinated care for women with postnatal depression

In many cases, postnatal depression is not identified or treated early enough, often as a result of poor co-ordination between the health professionals involved. This article outlines a project to develop multidisciplinary working to improve the care provision for women with postnatal depression.