dmcanzi@watserv1.uwaterloo.ca (David Canzi) (06/01/91)
Morbidity and Mortality Weekly Report
Thursday May 16, 1991
Current Trends
Preliminary Analysis: HIV Serosurvey of Orthopedic Surgeons, 1991
Although occupational transmission of human immunodeficiency virus (HIV)
and other bloodborne pathogens to health-care workers from patients has been
well documented, data on HIV seroprevalence in health-care workers are
limited. This report summarizes preliminary findings from a voluntary,
anonymous HIV serosurvey among orthopedic surgeons, conducted by CDC in
cooperation with the American Academy of Orthopaedic Surgeons (AAOS), at the
AAOS annual meeting in Anaheim, California, during March 6--12, 1991.
All orthopedic surgeons registered for the meeting who were in
postgraduate orthopedic surgical training programs, in practice, or retired
from practice in the United States or Canada were invited to participate.
Participants received pretest counseling, provided verbal informed consent,
and completed an epidemiologic questionnaire to ascertain demographic and
clinical practice characteristics, as well as the presence of nonoccupational
risk factors for HIV infection.* Names or other personal identifiers were not
collected. Blood specimens were screened for HIV antibody by enzyme
immunoassay (EIA); specimens repeatedly reactive by EIA were evaluated by
Western blot within 48 hours. HIV results and posttest counseling were
provided anonymously to participants at the serosurvey site.
To assess the representativeness of serosurvey participants,
characteristics of this group were compared with those of all orthopedic
surgeons who had completed a questionnaire survey (``Orthopaedic Surgeon
Survey'') administered by AAOS in November 1990. This survey of demographic
and clinical practice characteristics was mailed to the 20,625 orthopedic
surgeons known to AAOS to be in training, in prac tice, or retired from
practice in the United States and Canada; responses were received from 10,411
(50%) (AAOS, unpublished data).
Of 7121 orthopedists attending the AAOS annual meeting who were eligible
for the serosurvey, 3420 (48%) participated. Based on the self-administered
questionnaire, most participants were male (97%) and aged 30--54 years (75%).
Compared with findings of the AAOS Orthopaedic Surgeon Survey, serosurvey
participants were more likely to be in residency or fellowship training (18%
vs. 14%); have trained or practiced in one or more geographic areas of high
acquired immunodeficiency syndrome (AIDS) incidence** since 1977 (75% vs.
69%); have operated on one or more patients with known HIV infection (49% vs.
43%); have had a patient's blood contact their skin in the previous month (87%
vs. 83%); and have sustained a percutaneous injury (e.g., needlestick or cut)
from a sharp object contaminated with a patient's blood in the previous month
(39% vs. 34%). Fifty-one percent of serosurvey participants had been tested
previously for HIV.
Of the 3420 serosurvey participants, two were HIV seropositive (0.06%,
upper limit 95% confidence interval (CI)=0.18%). In addition, eight specimens
were reactive by EIA but indeterminate by Western blot; based on further
testing at CDC with investigational peptide EIAs and recombinant DNA antigen
assays for HIV antibody, seven of the eight specimens were classified as HIV-
antibody negative and one as indeterminate.
Each of the two HIV-seropositive participants reported nonoccupational
risk factors for HIV infection; therefore, among the 108 surgeons reporting
such risk factors, HIV seroprevalence was 1.9% (upper limit 95% CI=5.7%). In
comparison, of the 3267 participants not reporting nonoccupational HIV risk
factors, none were HIV positive (upper limit 95% CI=0.09%). Of the 45
participants who did not respond to the question on risk factors, none were
HIV positive. The one surgeon whose serum tested indeterminate for HIV
antibody did not report a nonoccupational risk.***
Both of the HIV-seropositive participants were male and reported having
performed surgery on patients with risk factors for HIV infection. One of the
two surgeons reported performing surgery on patients with known HIV infection
or AIDS. Although they had both sustained percutaneous injuries in the
previous year, neither reported an injury from a sharp object contaminated
with the blood of a patient known to have HIV infection or AIDS. The surgeon
with an indeterminate result, a man who had retired from clinical practice,
reported never having operated on a patient with known HIV infection or AIDS
or on a patient with risk factors for HIV infection or AIDS.
Although HIV testing of the serosurvey participants has been completed,
testing for markers of hepatitis B and C virus infection is in progress.
Additional analyses to assess representativeness of serosurvey participants
and to characterize the nature and frequency of their occupational contact
with blood are also under way.
Reported by: American Academy of Orthopaedic Surgeons Serosurvey Study
Committee. AIDS Activity, Hospital Infections Program, and Laboratory
Investigations Br, Div of HIV/AIDS, Center for Infectious Diseases, CDC.
Editorial Note:The findings of this HIV serosurvey assist in evaluating the
risk for occupationally acquired HIV infection in a subset of health-care
workers with frequent occupational blood contact, including percutaneous
injuries (4--6). Although these results may not be generalizable to all
orthopedic surgeons, the findings do not indicate a high rate of previously
undetected HIV infection among a large group of these surgeons, including
those who trained or practiced in areas of high HIV/AIDS incidence.
This serosurvey has at least three limitations. First, orthopedic
surgeons who attended the AAOS annual meeting and participated in this study
may not have been representative of all orthopedic surgeons in the United
States. However, preliminary analysis suggests that the likelihood of
occupational HIV exposure was at least as high for serosurvey participants as
for the more than 10,000 surgeons responding to the AAOS Orthopaedic Surgeon
Survey. Second, HIV seroprevalence may have been underestimated if orthopedic
surgeons who knew they were HIV positive declined to participate. Third, the
reliance on self-reporting may have affected the accuracy of the data on
nonoccupational risk factors for HIV infection.
The frequency of occupational blood contact and percutaneous injury
reported by serosurvey participants and AAOS Orthopaedic Surgeon Survey
respondents emphasizes the need for orthopedic surgeons and other health-care
workers who are potentially exposed to blood and body fluids to continue to
take appropriate precautions to prevent infection with HIV and other
bloodborne pathogens. As previously recommended by CDC, such workers should
receive hepatitis B vaccine, employ universal precautions, and receive
appropriate counseling and follow-up after occupational exposure to HIV or
hepatitis B virus (7--10). AAOS has developed additional recommendations for
the prevention of HIV transmission during orthopedic surgery (11--13); copies
are available from AAOS, 222 South Prospect Avenue, Park Ridge, IL 60068.
References
1. CDC. HIV/AIDS surveillance report. Atlanta: US Department of Health and
Human Services, Public Health Service, CDC, December 1990:1--18.
2. CDC. Interpretation and use of the Western blot assay for serodiagnosis of
human immunodeficiency virus type 1 infections. MMWR 1989;38(no. S-7).
3. Dock NL, Kleinman SH, Rayfield MA, Schable CA, Williams AE, Dodd RY. Human
immunodeficiency virus infection and indeterminate Western blot patterns. Arch
Intern Med 1991;151:525--30.
4. Panlilio AL, Foy DR, Edwards JR, et al. Blood contacts during surgical
procedures. JAMA 1991;265:1533--7.
5. Tokars JI, Marcus R, Culver DH, Bell DM, Cooperative Study Group. Blood
contacts during surgical procedures (Abstract). Program and abstracts of the
30th Interscience Conference on Antimicrobial Agents and Chemotherapy.
Washington, DC: American Society for Microbiology, 1990:246.
6. Gerberding JL, Littell C, Tarkington A, Brown A, Schecter WP. Risk of
exposure of surgical personnel to patients' blood during surgery at San
Francisco General Hospital. N Engl J Med 1990;322:1788--93.
7. CDC. Recommendations for prevention of HIV transmission in health-care
settings. MMWR 1987;36(no. 2S).
8. CDC. Update: universal precautions for prevention of transmission of human
immuno deficiency virus, hepatitis B virus, and other bloodborne pathogens in
health-care settings. MMWR 1988;37:377--82,387--8.
9. CDC. Public Health Service statement on management of occupational
exposure to human immunodeficiency virus, including considerations regarding
zidovudine postexposure use. MMWR 1990;39(no. RR-1).
10. ACIP. Protection against viral hepatitis: recommendations of the
Immunization Practices Advisory Committee (ACIP). MMWR 1990;39(no. RR-2).
11. American Academy of Orthopaedic Surgeons Task Force on AIDS and
Orthopaedic Surgery. Recommendations for the prevention of human
immunodeficiency virus (HIV) transmission in the practice of orthopaedic
surgery. Park Ridge, Illinois: American Academy of Orthopaedic Surgeons, 1989.
12. American Academy of Orthopaedic Surgeons/National Association of
Orthopaedic Nurses. Reducing the risk of blood-borne disease transmission in
orthopaedic surgery (Videotape and booklet). Park Ridge, Illinois: American
Academy of Orthopaedic Surgeons, 1991.
13. American Academy of Orthopaedic Surgeons. Advisory statement: HIV-infected
orthopaedic surgeons. Park Ridge, Illinois: American Academy of Orthopaedic
Surgeons, 1991.
*Including receipt of blood transfusion during 1978--1985; receipt of clotting
factor concentrate since 1977 for treatment of hemophilia or other coagulation
disorder; male-male sexual contact at any time since 1977; intravenous-drug
use since 1977; birth in Haiti or in central or east Africa; or sexual contact
since 1977 with someone in one of the above groups. Participants were not
asked which specific risk factor(s) applied to them.
**One of 26 U.S. metropolitan areas reporting the highest cumulative number
of AIDS cases (1) or in Africa or the Caribbean.
***In general, among persons who are indeterminate for HIV antibody but
without HIV risk factors, subsequent evaluation does not confirm HIV infection
(2,3).
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Volume 4, Number 11 May 27, 1991
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