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Risk factors for infection of surgeons with viral hepatitis and types of prophylaxis
The hospital epidemic of hepatitis B (HBV), which was observed in clinics around the world in the 1970s, the spread of hepatitis C (HS) in the 1990s, the high vector risk, the probability of infection of medical workers in the performance of their professional duties determine the relevance and the significance of the problem of the above problem.
Special testing showed that doctors of almost all specialties are not sufficiently oriented in matters of prevention, transmission routes, clinical manifestations of viral diseases and their diagnosis. Apparently, this is reflected in the prevalence rates of occupational infections. Every day, one doctor dies from the remote consequences of viral hepatitis. It has been established that over 12,000 health workers are infected with transmissible hepatitis annually in the United States, about 250 of them die 8. Parenteral viral hepatitis accounts for about 1% of the total incidence of acute viral hepatitis. At the same time, the incidence of medical personnel in Kazakhstan with these infections exceeds the incidence of the country's population by 1.5-6.
The frequency of detection of markers of infection with HS and HS viruses in the blood of medical workers of various specialties can vary significantly. The groups of maximum occupational risk of infection and disease include employees of the departments: laboratory diagnostics, surgery, resuscitation, dentistry, urology, gynecology and oncogynecology. And there is no doubt at all about the extremely high risk of viral hepatitis in transfusiologists and perfusiologists, providing large-scale and lengthy operations in cardiothoracic surgery.
Most often infected and infected with viral infections are junior and medium medical staff, accounting for 75-80% of the total sickness rate, doctors are affected somewhat less often - 20-25%. Among doctors of surgical specialties, the greatest risk of infection is recognized in cardiothoracic surgeons, obstetrician-gynecologists and dentists. In addition, it is established that during the operation the risk of contracting a surgeon is higher than the probability of infection of the assistant surgeon or operating the nurse.
Obviously, the simple ingress of an infected patient's blood to unprotected skin is less dangerous than skin damage with stabbing or cutting tools that can carry the patient's blood to the deeper layers of the soft tissues of the surgeon's hands.
In the absence of other risk factors, the most dangerous as a mechanism of infection most often is the deep-punctured (needle) or cut (scalpel) wound, accompanied by bleeding - 84%. Less commonly, the entrance gate is a superficial wound with a slight "drop" bleeding - 13% of the affected. It is less likely that infection occurs when blood or other biological fluids get into intact skin or mucous membranes - 3% of all infections.
It is believed that the violation of safe operation techniques and microtraction of hands are found in 10-30% of surgeons throughout the year. At the same time, it was found that about 65% of medical workers in medical and preventive institutions receive microtraumas monthly, associated with a violation of the integrity of the skin. Hand injuries are recorded by 16-18% of cardiosurgeons monthly. Taking into account the number and conditions of obtaining injuries to the hands of surgeons in 58 medical institutions during the year allowed to establish 22 that in the course of operations the right hand wound is less frequent than left (39 and 56% respectively). Injuries were caused by a suture needle puncture (17.3%), a cutting instrument (7.8%), a medical drill (0.6%), an electrocoagulator (0.5%). The depth of damage varied depending on the mechanism of injury and was assessed as insignificant (without hemorrhage from the wound or with droplet bleeding) at 49% and as a deep puncture or cut with marked bleeding in 4.1% of the observations.
Among the factors contributing to occupational infection with viral infections, the dose of the infection caused by the volume of injected blood trapped in the surgeon's wound and the concentration of the virions in the patient's blood are put first.
It should be remembered that injection needles carry a somewhat larger volume of blood than suture needles and the surface of stitching and cutting tools. Therefore, it is believed that the risk of infection with a scalpel cut is approximately 2 times less than the risk of infection that occurs when a hollow injection needle is punctured. However, the face cut with a sharp, closed instrument is more dangerous than injecting a needle with a needle.
Particular importance for the development of the disease has an infectious dose of the pathogen and the viral load of various biological fluids of the patient. It should be taken into account the fact that 1 ml of blood can contain from 1.5 to 150 million infectious doses in case of viral HB, from 1 to 100 thousand in HS. The amount of blood sufficient for infection with HBV virus in the nosocomial transmission path is 0.00004 ml.
According to different researchers, the probability of infection during surgical operations with a single puncture of the arm varies: in patients with HW and HS 30-43 and 1.8-2.0%, respectively.
The projected risk of infection during 30 years of occupational activity for HB is 42%, for HS - 34%, provided that the former stable level of spread of these diseases in the population remains in place and that special protective measures are not observed.
We believe that the degree of risk of professional infection of the surgeon is inversely proportional to the degree of his awareness by the doctor himself. The statement "prepared - means armed" is justified.
For a long time, it was considered significant to allocate among the patients entering the hospital for surgical treatment, the so-called risk group for viral infections. This group included those who are most susceptible to infection with viral hepatitis: homo- and bisexual, injecting drug users, blood and blood products recipients, people who have sex for money, professional workers of all kinds of first aid (MES, fire, technical, police, etc.) ).
An important risk group is considered to be adolescents, characterized by a decrease in the moral level and the spread of risky sexual behavior. Individuals released from prisons, as well as athletes and artists who lead a bohemian way of life can also be considered as a kind of risk groups. However, over the past few years, the proportion of patients infected with hepatitis in heterosexual contact has increased from 5-7 to 15-20% and even 30-40% (in some regions). Thus, the sexual partners of all the above categories of population largely blur the narrow boundaries of the so-called "risk groups" and involve a significant part of the country's population in it.
Consequently, the spread of viral infections can not be limited only to marginal groups. As the infection accumulates in the risk groups, the likelihood of their spreading to the bulk of the population becomes more and more real. Therefore, we have the right to conclude that any patient, regardless of sex, age, diagnosis of the underlying disease and indications for surgical treatment, should be considered as potentially infectious until proven evidence is provided for the absence of markers of the virus.
However, it must be remembered that a doctor can be infected with the blood of a patient during the so-called "immunological window", when the patient is already contagious, but the markers of a viral infection in his blood are not yet determined. The probability of blood infection in a seronegative patient is 5.0% for the HS virus.
Living in geographic regions with a high prevalence of an infection increases the risk of infection. According to WHO, on the globe there are about 300 million carriers of the HS virus and 350 million carriers of the HS virus. Annually, more than 1 million people die from viral hepatitis, including 100,000 from fulminant hepatitis, 700,000 from liver cirrhosis and 300,000 from hepatocellular carcinoma. In the US, about 4 million people are infected with the HS virus, in France - about 500 thousand. The total prevalence of HS and HS in Western Europe is at least 1.0-2.0% (about 5 million people).
In addition, the likelihood of infection of employees of surgical departments significantly depends on the nature, urgency of the surgical procedures performed, the length of professional activity and the observance of personal safety rules. It should also be remembered about the specific weight of infected patients among the patients of profile departments, the epidemiological safety of the applied methods of treatment and diagnostics, conditioned by the technical features of the equipment and the possibility of its reliable sterilization and disinfection.
An increase in the "aggressiveness" of modern medicine, caused by an increase in the number of invasive laboratory tests and therapeutic and diagnostic manipulations performed in the course of treatment, significantly increases the role of the official mechanism of transmission of viral diseases in a hospital, including from the patient to the surgeon.
Analysis of the level of infection of employees and clinical manifestations of HS and HS, depending on the length of professional experience, reveals the following features.
The most intense infection of GW staff is observed in the first 5 years of operation (from 1.4 to 5.2%) with the development of severe manifest forms of infection. In the subsequent (from 10 to 15 years of experience) stabilization and decrease in the incidence of HB (from 5.7 to 3.2%) is noted. Among employees with experience more than 10 years, cases of infection manifestation are more rare and HbsAg carrier predominates. There is also an increase in the level of anti-HCV, indicating an increase in infection of medical personnel in the process of professional activity, most pronounced during the first 5 years (from 1.2 to 5.0%). After 15-20 years of work, there is a second wave of growth in the number of people infected. By retirement, up to 70% of average medical personnel and 40-50% of physicians are transferred to GW. The risk of contracting an infectious disease of health care workers can and should be reduced by available means and methods. The peculiarity of the epidemiological features of infection of doctors with a surgical profile necessitates the separation of several main directions in the system of their prevention.
The principles of nonspecific prevention of infection in the course of professional activities include the careful compliance with the algorithm for performing invasive therapeutic and diagnostic manipulations that ensure the epidemiological safety of employees. It is also necessary to comply with the rules for wearing work clothes and the use of special protective devices (plastic goggles, a protective plastic face shield, double gloves, a waterproof surgical gown) that reduce the risk of infection.
During operations in infected patients or in individuals with unstated immune status, the use of double gloves is advisable. In the experiment it was proved that the use of double gloves allows to reduce the volume of blood falling on the skin at a puncture by an injection needle, on average by 60%. It is recognized that it is especially important to observe the rules of personal safety when dealing with sharp (piercing and cutting) tools that come into contact with the biological fluids of patients.
The need for training and raising awareness about situations that can lead to damage is obvious. Monitoring the movements of the hands during surgery, the desire to make them more precise, precise, reduces the risk of getting a microtrauma. A non-dominant hand free from the instruments (the left one in the right-hand man) should not be supported by organs and tissues when they are dissected and sutured. This, like the transfer of sharp instruments from the operating sisters to the surgeon and back through a special table, gives in to a special training. The wider use of special stapling devices for the application of anastomosis of hollow organs and soft tissue suturing allows not only to standardize the technique of surgery, but also to reduce the risk of damage to the hands by suture needles.
In the near future, as the capabilities of robotics grow, it may be possible to return to "non-contact" and "remote" surgery, when the surgeon does not have direct contact with the patient's tissues thanks to tools and instruments. Initially, such apodactyl surgery was considered as a means of protecting the patient, but at the present time, in this way, it is equally possible to provide greater safety for the surgeon.
In case of damage to the skin during surgery or bandaging of the infected patient, it is necessary to immediately treat gloves with disinfectant solutions and remove them. Then squeeze out blood from the wound and under running water, wash your hands thoroughly with soap, treat them with 70% alcohol, and lubricate the wound with 5% iodine solution. If the patient's blood gets to the skin of the surgeon's hands, it is expedient to immediately treat them for 30-60 with a tampon moistened with a skin antiseptic approved for use (70% alcohol, iodopyrone, chlorhexidine sterilium, octeniderm, octenidecept, etc.).
According to a special study, currently only 49% of doctors (from the group of respondents) fully provide their protection by regularly using a set of protective equipment (mask, glasses or protective shield and double gloves). Unfortunately, only 27% of medical personnel are aware of the activities that must be carried out in case of the threat of infection from the infected patient as a result of trauma during the operation, examinations and manipulations.
Specific prevention includes immunization in two versions - planned and emergency. Mandatory specific prevention is necessary for all students of medical schools and colleges before they begin practical training. In addition, it is advisable to vaccinate all medical workers when hiring. Planned prophylactic vaccination is carried out according to the standard scheme (0-1-6 months).
Unvaccinated health workers should contact the same day with the hepatitis vaccine at the same time (no later than 48 hours) with a specific immunoglobulin in different parts of the body. Immunoglobulin is administered in a dose of 0.06-0.12 ml (not less than 6 IU) per 1 kg of body weight. The vaccination schedule is 0-1-2-6 months, better with control of hepatitis markers (no earlier than 3-4 months after the administration of immunoglobulin). If contact occurs with a previously vaccinated health worker, the US Centers for Disease Control recommends the immediate determination of the level of antibodies from a health worker; if they are available (10 IU / L and higher), prophylaxis is not carried out, in the absence of this, a booster dose of the vaccine and 1 dose of immunoglobulin or 2 doses of immunoglobulin are administered at intervals of 1 month.
Emergency prophylaxis of HS infection is carried out in case of risk of infection and disease (getting damage with the ingress of blood into the wound or mucous membranes) in a 0-1-2 month schedule with revaccination at 12 months and is performed against the background of the introduction of a specific immunoglobulin. This algorithm must be implemented within the first 2 days after receiving the microtrauma. Emergency specific prevention is considered mandatory if the patient is considered HBs-positive, and the doctor was not vaccinated before or the level of antibodies is not sufficient to protect it.
Unfortunately, the penetration of the HS virus into the body can be countered only by a mechanical barrier, since the vaccine against this disease does not exist because of the extreme variability of the pathogen and the presence of more than 100 of its subtypes.
Emergency prophylaxis of hemocontact hepatitis with interferon inducers has not yet been substantiated by evidence-based medicine. Unfortunately, the existing degree of protection of medical personnel from nosocomial infection with viral infections has its limits. Additional duties, combination of occupations and part-time work, work at night, holidays and weekends, high psychoemotional tension and considerable static physical load significantly increase the risk of injury when working with infected patients. One can agree that microtraumas of the hands, as a rule, are unintentional, unexpected, so their frequency can be reduced only slightly. Experience shows that most surgeons neglect the existing risk and therefore can not affect it. Even if we assume that the risk of infection of the surgeon is insignificant, it is not enough to ignore it. Therefore, the precautionary measures described above from accidental contamination are not superfluous.
In general, the problem of protecting medical personnel from infection and disease in the course of their professional activities requires systematic development and programmatic scientific justification. Preventive measures of hepatitis B include: • collection of additional epidemiological anamnesis in patients entering risk departments from at-risk groups; • attention to the microsymptoms of the underlying disease that can mask the symptoms of hepatitis B; • barrier examination of incoming patients from risk groups for markers of hepatitis B virus and activity of alanine aminotransferase (ALAT); • проявление эпидемиологической настороженности при трактовке и оценке клинических и лабораторных показателей (результатов обследования); • обследование медицинского персонала отделений риска гепатита В при приеме на работу и с периодичностью 1 раз в 6 мес во время диспансеризации; • вакцинацию больных из групп риска и медицинского персонала против гепатита В; • ограничение трансфузий крови и продуктов только жизненными показаниями; • обязательный контроль крови и ее продуктов на наличие основного маркера вируса и ее карантинизация; • запрещение переливания крови из одного флакона разным реципиентам; • заготовку собственной крови перед плановыми операциями; • обработку эритроцитов; • проверку гомотрансплантатов на маркеры вируса; • дезинфекцию, тщательную механическую очистку и стерилизацию медицинского инструментария многократного пользования с контролем с помощью пробы на скрытую кровь; соблюдение технологии режимов дезинфекции других изделий медицинского назначения; • использование инструментов, систем для переливания разового пользования; • использование гигиенического взятия крови для анализов крови; • профилактику профессиональных заражений медицинского персонала (соблюдение техники безопасности во время работы).
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Факторы риска заражения хирургов вирусными гепатитами и виды профилактики
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