Transcript Document

LOOMING CLOUDS
The threat of AIDS
Dr Sanjay De Bakshi
MS(Cal.); FRCS(Eng.);FRCS(Edin).
An estimated 2 to 5 million
Indians affected (1997
NACO study)
“Addressing some myths”
Which group has the highest
incidence of HIV in India?
1. Unmarried women?
2. Divorced and separated women?
3. Married women?
Which profession is most
affected?
•
•
•
•
•
•
•
•
•
Skilled labour?
Service?
Professional?
Labourer?
Housewife/Unemployed?
CSW?
Business?
Vendor?
Clerk?
Spread of AIDS
the “Ripple effect”
GENERAL
CORE
GROUP
BRIDGING
GROUP
POPULATION
Prevalence of AIDS in India
• The problem of India is
that of a large body of
unsuspecting,
uneducated general
public.
• The problem of medical
personnel and surgeons
in particular, is that of
treating patients many
of whom will have the
disease without realising
it.
Status and Stats for India
Cases of HIV in India
Could Surpass South
Africa By Brian Carnell
Wednesday, May 8, 2002
TELEGRAPH 22nd January
2001
“AIDS cloud on housewives”
2.5
PER2
CENT
1.5
1
0.5
“NACO”
0
MUMBAI
BANGALORE
CALCUTTA
DELHI
Stats for India ; Southern & Central
Population Screened
800000
700000
600000
500000
400000
300000
200000
100000
0
AP
Goa
Ker
Mahrst
TN
Karn
MP
Stats for India; Southern & Central
Number Tested Positive
60000
50000
40000
30000
20000
10000
0
AP
Goa
Ker
Maha
TN
Karn
MP
Stats for India; Southern & Central
Seropositivity Rate{per Thousand}
120
114.33
100
80
60
40
20
35.24
20.02
9.44
14.53
4.83
9.36
0
AP
Goa
Kerala
Maha
TN
Karn
MP
• The Statesman on
26th Aug. 2002
carried the story of
4 young doctors, 2
from King George
Medical College,
Lucknow and 2
from Kanpur
Medical College
who tested positive
for HIV.
• Dr Bachittar Singh;
Project Director of
Uttar Pradesh
AIDS Control
Society confirmed
officially that they
had acquired the
infection while
treating patients
with HIV.
PROBLEM OF AIDS
for the Health Care Provider
PROBLEM
FOR THE
HEALTH CARE
PROVIDER
DIAGNOSIS &
TREATMENT
TRANSMISSION
OF THE
AIDS VIRUS
PATIENT-TO DOCTOR
DOCTOR-TOPATIENT
PATIENT - TO
PATIENT
FACTS
The HIV Virus has been isolated
in the following:SECRETIONS
BLOOD
VAGINAL
EXCRETIONS
SECRETIONS
SALIVA
MILK
URINE
SEMEN
CSF
TEARS
AMNIOTIC
FLUID
FACTS
Some trials
853 Health care
Workers
708 PERCUTANEOUS
NEEDLE-STICK
INJURIES (80%)
175 MUCOUS MEMBRANE
OR OPEN WOUND
CONTAMINATED BY BLOOD
(20%)
425 tested in the acute
and convalescent phase
376 tested only in the
convalescent phase
351 PERCUTANEOUS
INJURIES
3 (0.9%)
SEROCONVERTED
74 NON-PERCUTANEOUS
INJURIES
NONE
SEROCONVERTED
1 TESTED POSITIVE
FOR HIV
FACTS
Some other trials
8 HEALTH CARE
WORKERS SEROCONVERTED
3 HAD
NEEDLE-STICK
INJURIES
2 HAD EXTENSIVE
CONTACT WITH BLOOD
AND OTHER BODY
FLUIDS
3 OTHERS HAD
NON-NEEDLE-STICK
INJURIES
one also had
a mucous membrane
exposure
All had skin lesions
which may have been
contaminated by
blood
All had direct contact
of their skin with
blood from infected patients
FACTS
A trial involving 1231 dentists:Only one was
found to be
sero-positive;
he NEVER
WORE
GLOVES“They are only
for sissies”he is reported
to have said.
Transmission is therefore a fact,
should we be testing ALL patients?
• First-there is an error rate(both +ve and -ve) for
both the ELISA and the Western Blot tests.
• Second-Infected patients may be in the “window
period” between exposure and sero-conversion.
• Third- testing requires the patient to consent. What
happens if the patient refuses?
• Fourth-though some doctors feel that they will be
able to take additional security measures for the HIV
patient, ALL studies show no statistical difference
between needle-prick and other exposures.
Continued• Fifth- Results of the tests may not be available
before surgery particularly in the emergency
setting.
• Sixth-Testing solely for HIV will not identify
those patients who pose other hazards to health
care workers. ( In one study, testing solely for HIV
alone would have failed to identify HBV in 87%
and HCV in 80%).
Committee for Disease Control
{CDC-Atlanta}
QUESTIONAIRRE PUT
TO ALL STAFF AT 2 PRIVATE HOSPITALS
One with a patient strength of 400
and the other 200.
SUGGESTED
PRECAUTIONS
EXISTING
PRACTICE
Suggested precautions (CDC)
• Routine use of gloves Surgery
 Examination of open wounds and
body fluids
 Venesection or other vascular
access
 Handling soiled material
• Non-permeable gowns and face
masks with visors should be used
when procedures likely to generate
splashes of blood or other body
fluid.
Results of a questionnaire from
two private hospitals in Kolkata
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
92%
8%
NO
YES
Do you wear gloves when you start an intravenous
infusion?
Precautions (contd.)• Hands and other skin surfaces
should be washed thoroughly if
contaminated.
• PREVENT “SHARPS” INJURY Needles should never be recapped
or broken by hand.
 Care should be taken when working
in closed spaces.
 “Sharps” should be placed in a
puncture-proof container.
 Containers should be placed as
close as possible to the work area.
''The public attention and awareness of this problem
has lagged behind the scope of it,'' said Dr. Linda
Rosenstock of the Centers for Disease Control and
Prevention.(November 1999.)
''For every 100 beds a hospital has, on
average it has 30 needle stick injuries
per year.''
Results of a questionnaire from
two private hospitals in Kolkata
80
70
60
50
40
30
20
10
0
YES
NO
Do you use your hand to recap needles?
Results of a questionnaire from
two private hospitals in Kolkata
0.8
73%
0.7
0.6
0.5
0.4
27%
0.3
0.2
0.1
0
YES
NO
Do you discard used needles and syringes in the usual
waste paper basket?
Precautions (contd.)
• Although not implicated yet,
providing for ventilation devices
will cut down on the need for
mouth-to-mouth resuscitation.
• All Health Care Workers with
open wounds or exudative
lesions should avoid risk.
• Food, drinks,re-applying
cosmetics and putting on
contact lenses should be
avoided in the working area.
Results of a questionnaire from
two private hospitals in Kolkata
0.7
65%
0.6
0.5
0.4
35%
0.3
0.2
0.1
0
YES
NO
Have you worked in the last 3 years with a cut on
your hand?
Transmission of the HIV Virus to
the patient
TRANSMISSION OF
THE VIRUSTO THE PATIENT
FROM AN HIV
POSITIVE DOCTOR
FROM IMPROPERLY
STERILISED
MEDICAL
EQUIPMENT
Transmission from an
HIV positive doctor
• The incidence of infection to a single patient
from an HIV positive doctor ranges from
0.0024%(1 in 42000) to 0.00024%(1 in
417000).
• However, the CUMULATIVE risk of
transmission of infection from an HIV positive
surgeon to a patient, considering his entire
surgical lifetime, is 8.0% to 8.1%.
• THESE STATISTICS -RESPONSIBLE FOR
LEGALLY DENYING AFFLICTED
DOCTORS, FROM CONTINUING TO
PRACTICE IN HIGH RISK JOBS IN THE
U.S.A.
Transmission from
Inadequately sterilised equipments
and
improperly tested blood.
•
•
•
•
Blood and needles.
Endoscopy units.
Dialysis departments.
Surgical instruments.
Transmission by ignorance!!!
“DEADLY SYRINGES REUSED IN THE U.S.A.”
Syringe manufacturers say it doesn't happen.
Doctors claim they wouldn’t dream of doing it, and
most patients have never even heard of it. But the
medical reuse of unsterile syringes in the United
States is a problem.
Last year a medical doctor, in Monroe, Conn.,
reportedly gave free flu shots to almost 500
people with syringes reused up to 10 times
each. Even after a nurse told town authorities what
had happened, the doctor refused to admit that he
had done anything wrong. “For years this has been
a perfectly acceptable procedure,” he told one
Connecticut television station. “I didn't know the
procedure had changed.”
Contd.:In 1995, a study published in the American Journal of
Anesthesiology found that 39 percent of anesthesiologists
reported using the same syringe on different patients.
PRINCIPLES OF ANTI-SEPSIS
Laid down ages ago.
• It will indeed be a
pity and a travesty
of justice, if in the
year 2002, we choose
to ignore their
teachings!!!!!
CDC GUIDELINES FOR
TREATMENT OF EXPOSURES
TYPE OF
EXPOSURE
Mucous membrane or
Skin with evidence of
weeping dermatitis
or open wound
Intact skin
Percutaneous exposure
VOLUME?
Normally no PEP
required.
VOLUME ?
Small eg. few
drops or short
duration
Large eg. several drops
or splash and duration
of several mins. or
more
Neglible risk;
Basic PEP to be
cosidered if source
HIV titre high or unknown.
Basic PEP regimen
Expanded regimen if
source HIV titre high
Less severe eg.
solid needle,
supfl. scratch.
More eg. large-bore
hollow needle, deep
puncture and visible
blood on device,
Expanded PEP
regimen
PEP REGIMENS SUGGESTED
BASIC
Zidovudine 600mgm
in divided doses and
Lamivudine 150mgm
b.i.d. for 28 days.
EXPANDED
Basic plus either
Indinavir 800mg t.i.d.
or
Nelfinavir750mgt.i.d.
THE ACTUAL STATISTICS
TODAY!
For him, there is no tomorrow,
his name is-