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)

LOOMING CLOUDSThe threat of AIDS

Dr Sanjay De BakshiMS(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 AIDSthe “Ripple effect”

CORE GROUP

BRIDGING GROUP

GENERAL

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”

0

0.5

1

1.5

2

2.5

MUMBAI BANGALORE CALCUTTA DELHI

““NACO”NACO”

PER-CENT

Stats for India ; Southern & Central Population Screened

0

100000

200000

300000

400000

500000

600000

700000

800000

AP Goa Ker Mahrst TN Karn MP

Stats for India; Southern & CentralNumber Tested Positive

0

10000

20000

30000

40000

50000

60000

AP Goa Ker Maha TN Karn MP

Stats for India; Southern & Central Seropositivity Rate{per Thousand}

9.44

35.24

4.83

114.33

20.0214.53

9.36

0

20

40

60

80

100

120

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

D IA G NO S IS &T RE A T M E NT

PA T IE NT -T O -D O C T O R

D O C T O R-T O -PA T IE NT

PA T IE NT - T OPA T IE NT

T RA NS M IS S IO NO F T HEA ID S V IRUS

PRO BL E MF O R T HE

HE A L T H C A REPRO V ID E R

FACTSThe HIV Virus has been isolated

in the following:-

SECRETIONS

EXCRETIONS

SALIVA

CSFTEARS

BLOOD

VAGINAL

SECRETIONS

MILK

SEMEN

AMNIOTIC FLUID

URINE

FACTSSome trials

708 PERCUT ANEOUSNEEDLE-ST ICKINJURIES (80% )

175 M UCOUS M EM BRANEOR OPEN W OUND

CONT AM INAT ED BY BLOOD(20% )

3 (0.9% )SEROCONVERT ED

351 PERCUT ANEOUSINJURIES

NONESEROCONVERT ED

74 NON-PERCUT ANEOUSINJURIES

425 tested in the acuteand convalescent phase

1 T EST ED POSIT IVEFOR HIV

376 tested only in theconvalescent phase

853 Health careW orkers

FACTSSome other trials

3 HADNEEDLE-ST ICK

INJURIES

2 HAD EXTENSIVECONTACT W IT H BLOOD

AND OTHER BODYFLUIDS

one also hada m ucous m em brane

exposure

All had skin lesionsw hich m ay have been

contam inated byblood

All had direct contactof their skin w ith

blood from infected patients

3 OTHERS HADNON-NEEDLE-ST ICK

INJURIES

8 HEALTH CAREW ORKERS SEROCONVERTED

FACTSA 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.

• 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.

Transmission is therefore a fact,should we be testing ALL patients?

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}

SUG G EST EDPRECAUT IONS

EXIST INGPRACT ICE

QUEST IONAIRRE PUTT O ALL ST AFF AT 2 PRIVAT E HOSPIT ALS

One w ith a patient strength of 400and the other 200.

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

92%

8%

0%

10%20%30%40%50%60%70%80%90%

100%

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

0

10

20

30

40

50

60

70

80

YES NO

Do you use your hand to recap needles?

Results of a questionnaire from two private hospitals in Kolkata

73%

27%

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

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

65%

35%

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

YES NO

Have you worked in the last 3 years with a cut on your hand?

Transmission of the HIV Virus to the patient

FROM AN HIVPOSIT IVE DOCT OR

FROM IM PROPERLYSTERILISED

M EDICALEQUIPM ENT

TRANSM ISSION OFTHE VIRUST O THE PAT IENT

Transmission from anHIV 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 fromInadequately sterilised equipments

andimproperly 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-SEPSISLaid 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

Neglib le r isk ;Bas ic PE P to be

cos idered i f sourceHIV ti tre h igh or unknow n.

S m all eg. fewdrops or short

dura tion

Bas ic PE P regim enE xpanded regim en i fsource HIV ti tre h igh

L arge eg. severa l dropsor splash and dura tion

of severa l m ins . orm ore

V O L UM E ?

M ucous m em brane orS k in w ith evidence of

w eeping derm ati tisor open w ound

Norm ally no PE Prequired.

Intac t sk in

L ess severe eg.sol id needle ,

supfl . sc ra tch.

E xpanded PE Pregim en

M ore eg. la rge -borehol low needle , deeppuncture and vis ib le

blood on device ,

V O L UM E ?

Percutaneous exposure

T YPE O FE X PO S URE

PEP REGIMENS SUGGESTED

BASIC Zidovudine 600mgmin divided doses andLamivudine 150mgmb.i.d. for 28 days.

EXPANDED Basic plus eitherIndinavir 800mg t.i.d.orNelfinavir750mgt.i.d.

THE ACTUAL STATISTICS TODAY!

For him, there is no tomorrow,his name is-