While the incidence of disease from HIV and hepatitis
is increasing in the United States, little is known about
their prevalence in patients undergoing surgery. Now,
researchers have shown that nearly 40 percent of surgeries
at The Johns Hopkins Hospital occur in patients who tested
positive for a blood-borne germ.
"While these rates are alarming, they are not entirely
unexpected. General precautions have been in effect for
some time to prevent the spread of disease to health care
workers in the operating room," says Martin A. Makary,
assistant professor of
surgery and public
health at Johns Hopkins and lead author of a report in
the May issue of Annals of Surgery.
"Given the high incidence of these infections,
however, we have developed new strategies such as
'sharpless' surgery — a surgical technique which uses
high-technology alternatives to needles and knives. We
advocate using these techniques whenever possible in
high-risk settings to further protect health care workers
from accidental transmission," Makary says.
Sharpless surgical techniques include laparoscopy,
electrocautery to replace scalpel incisions, and skin clips
or glue instead of sewing to close or repair wounds.
Previous studies have shown that health care workers
are injured in about 7 percent of operations. As many as 87
percent of surgeons will receive an injury that breaks the
skin — thus allowing for possible disease
transmission — at some point in their career. There
are an estimated 40,000 new cases of HIV each year, and
hepatitis C is increasing at an even faster rate, according
to the report. The study concludes that by studying the
rates of HIV and hepatitis B and C among patients
presenting for surgery, a more accurate incidence of
disease is measured within a community, bypassing the
selection bias of traditional statistics of known infected
patients presenting to primary care clinics. Furthermore,
the authors report that blood-borne pathogens are
associated with certain types of operations.
The researchers also found that the operations
associated with the greatest risk of infection —
lymph-node biopsy, soft-tissue-mass excision and
abscess-drainage cases — were often assigned to the
most inexperienced surgeons in training, placing them at
greatest risk.
"Sharpless surgical techniques combined with
traditional precautions and early education for surgery
trainees are the most practical ways to reduce the risk of
infection to health care workers," Makary says.
The researchers studied 709 consecutive adult general
surgery operations performed between July 2003 and June
2004 in the community surgical service at The Johns Hopkins
Hospital including inpatient, emergency department and
outpatient surgical procedures. Data were collected on HIV,
hepatitis B and hepatitis C test results; type of
operation; and the patient's age, sex and history of
intravenous drug use.
The researchers found that 38 percent of all
operations involved a blood-borne pathogen, and almost half
(47 percent) of all men tested positive for at least one
infection. HIV accounted for 26 percent of infections,
hepatitis B for 4 percent, hepatitis C for 35 percent and
co-infection with HIV and hepatitis C for 17 percent.
In addition, blood-borne pathogen infection was found
in up to 65 percent of patients with a history of
intravenous drug use and in as many as 71 percent of
patients undergoing a soft-tissue abscess procedure or
lymph-node biopsy.
While the patients in this study tend toward low
socioeconomic status and increased substance use, most
university hospitals in the United States are located in
urban areas and serve a similar patient population, Makary
says.
Other authors on the report are Eric S. Weiss, Theresa
Wang, Dora Syin, Peter Pronovost, David Chang and Edward
Cornwell III.