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Risk factors for infection of surgeons with viral hepatitis and types of prevention

The hospital epidemic of hepatitis B (HBV), observed in clinics around the world in the 70s of the last century, the spread of hepatitis C (HS) in the 90s, high transmissible risk, the likelihood 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 has shown that physicians of almost all specialties are not well oriented in matters of prevention, transmission routes, clinical manifestations of viral diseases and their diagnosis. This seems to be reflected in the prevalence rates of occupational infections. Every day, one doctor dies in the world from the long-term effects of viral hepatitis. It is estimated that more than 12,000 health workers are infected in the United States each year with transmission hepatitis, about 250 of them die 8. Parenteral viral hepatitis accounts for about 1% of the overall incidence of acute viral hepatitis. At the same time, the incidence rate of medical personnel in Kazakhstan with these infections exceeds the incidence rates of the country's population by 1.5-6.

The frequency of detection of markers of infection with HBV and HBV viruses in the blood of health care workers of various specialties can vary significantly. The maximum occupational risk groups for infection and disease include employees of the following departments: laboratory diagnostics, surgery, resuscitation, dentistry, urology, gynecology and oncologic gynecology. And there is absolutely no doubt about the extremely high risk of viral hepatitis among transfusiologists and perfusiologists, who provide large-scale and long-term operations in cardiothoracic surgery.

Most often, the junior and nursing personnel are infected and become infected with viral infections, making up 75-80% in the general structure of the diseased, and doctors are less often affected - 20-25%. Cardiothoracic surgeons, obstetrician-gynecologists and dentists have the highest risk of infection among surgical physicians. In addition, it was found that during the operation, the risk of infection of the surgeon is higher than the probability of infection of the assistant surgeon or operating sister.

It is obvious that a simple hit of the blood of an infected patient on unprotected skin is less dangerous than damage to the skin with piercing or cutting tools that can transfer 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 one most often appears as a mechanism of infection - a deep stab (with a needle) or a cut (with a scalpel) wound, accompanied by bleeding - 84%. Less commonly, the entrance gate is a superficial wound with minor “drop” bleeding - 13% of the victims. Infections are less likely to occur if blood or other biological fluids come into contact with intact skin or mucous membranes - 3% of all infections.

It is believed that the violation of the technique of safe operation and microtrauma of the hands occur in 10-30% of surgeons during the year. At the same time, it was found that about 65% of medical workers at medical institutions receive a monthly microtrauma associated with the violation of the integrity of the skin. Hand injuries are recorded in 16-18% of heart surgeons monthly. Accounting for the number and conditions for obtaining injuries to the hands of surgeons in 58 medical institutions over the course of the year made it possible to establish 22 that injuries of the right hand occur less frequently than left during operations (39 and 56%, respectively). The injuries were caused by a puncture with a suture needle (17.3%), a cutting tool (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 bleeding from a wound or with drip bleeding) at 49% and as a deep puncture or cut with pronounced bleeding in 4.1% of observations.

Among the factors contributing to occupational infection with viral infections, in the first place put the dose of infekt due to the volume of injected blood that fell into the wound of the surgeon, and the concentration of virions in the patient's blood.

It should be remembered that injection needles carry a slightly larger volume of blood than suture needles and the surface of piercing and cutting tools. Therefore, it is considered that the risk of infection when cut with a scalpel is approximately 2 times less than the risk of infection arising from the puncture of a hollow injection needle. However, a face cut with a sharp, contracted instrument is more dangerous than an injection needle.

Of particular importance for the development of the disease is the infectious dose of the pathogen and the viral load of various biological fluids of the patient. It is necessary to take into account the fact that 1 ml of blood may contain from 1.5 to 150 million infectious doses for viral HBs, from 1 to 100 thousand for HSs. The amount of blood sufficient for infection with the HBV virus during the nosocomial route of transmission 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 HB and HS 30-43 and 1.8-2.0%, respectively.

The predicted risk of infection within 30 years of professional activity for HBG is 42%, for HS it is 34%, provided that the prevailing stable level of the spread of these diseases in the population and non-observance of special protection measures are maintained.

We believe that the degree of risk of occupational infection of a surgeon is inversely proportional to the degree of his awareness by the doctor himself. True, the statement “prepared means armed”.

For a long time, the selection among patients admitted to the hospital for surgical treatment, the so-called risk group for viral infections, was considered significant. This group included those who are most susceptible to infection with viral hepatitis: homo-and bisexuals, injecting drug addicts, recipients of blood and blood products, people having sex for money, professional workers of all types of ambulance (EMERCOM, fire, technical, police, etc. ).

An important risk group is considered to be adolescents, which are characterized by a decrease in the moral level and the spread of risky sexual behavior. Peculiar risk groups can also be considered as persons released from prison, as well as athletes, artists, leading a bohemian lifestyle. However, over the past few years, the proportion of patients infected with hepatitis during heterosexual contact has increased from 5-7 to 15-20% and even 30-40% (in some regions). Thus, the sexual partners of all the categories of population listed above largely blur the narrow borders of the so-called “risk groups” and involve a significant part of the country's population in it.

Consequently, the spread of viral infections cannot be limited only by marginal groups. As the infection accumulates in risk groups, the probability of their spreading in the majority of the population becomes more and more real. Therefore, we have the right to conclude that any patient, regardless of gender, age, diagnosis of the underlying disease and indications for surgical treatment, should be considered as potentially infected until reasonable evidence is given of the absence of markers of carcinogenesis.

However, it is necessary to remember that the doctor may be infected with the patient’s blood 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 infection with the blood of a seronegative patient is 5.0% for HBV virus.

Living in geographic regions with a large spread of a particular infection increases the risk of infection. According to WHO, there are about 300 million carriers of the HS virus and 350 million carriers of HBV globally. Annually, more than 1 million people die from viral hepatitis in the world, including 100 thousand from fulminant hepatitis, 700 thousand from liver cirrhosis and 300 thousand from hepatocellular cancer. In the US, about 4 million people are infected with the HS virus, in France - about 500 thousand. The total prevalence of HBV 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 largely depends on the nature, urgency of surgical interventions, professional experience and compliance with personal safety rules. It should be remembered about the proportion of infected patients among the patients of specialized departments, the epidemiological safety of the applied methods of treatment and diagnosis, due to the technical features of the equipment and the possibility of reliable sterilization and disinfection.

The increase in the “aggressiveness” of modern medicine, due to the increase in the number of invasive laboratory tests and therapeutic and diagnostic procedures performed during treatment, significantly increases the role of the artifactual mechanism of transmission of viral diseases in the hospital, including from patient to surgeon.

Analysis of the level of infection of employees and the clinical manifestations of HS and HS depending on the length of professional activity reveals the following features.
The most intense infection of HBG employees is observed in the first 5 years of work (from 1.4 to 5.2%) with the development of severe manifest forms of infection. Subsequently (from 10 to 15 years of experience), stabilization and decrease in the incidence of HBV (from 5.7 to 3.2%) is noted. Among employees with an experience of more than 10 years, cases of infection manifestation are more rare and HbsAg carriage prevails. An increase in the level of anti-HCV is also detected, indicating an increase in infection of medical personnel in the course of their professional activities, most pronounced during the first 5 years (from 1.2 to 5.0%). After 15-20 years of work, the second wave of growth in the number of infected is observed. Up to 70% of the nursing staff and 40-50% of doctors tolerate HB to retirement. The risk of contracting an infectious disease by medical professionals can and should be reduced by using available means and methods. The peculiarity of the epidemiological features of infection of surgical physicians necessitates the identification of several main directions in the system of their prevention.

The principles of non-specific infection prevention in the course of professional activity should include careful adherence to the algorithm for performing invasive treatment and diagnostic procedures that ensure the epidemiological safety of employees. It is also necessary to observe the rules of wearing working clothes and the use of special protective devices (plastic glasses, protective plastic screen on the face, double gloves, waterproof surgical gown) that reduce the risk of infection.

During operations in infected patients or in persons with unidentified immune status, it is advisable to use double gloves. In the experiment it was proved that the use of double gloves allows you to reduce the volume of blood falling on the skin when punctured by an injection needle, on average by 60%. It is recognized as particularly important to observe the rules of personal safety when handling sharp (piercing and cutting) instruments in contact with the biological fluids of patients.

There is an obvious need for training and raising awareness of situations that can lead to damage. The control of hand movements during the operation, the desire to make them more accurate, precise, reduces the risk of microtrauma. A non-dominant tool-free hand (left with a right-handed person) should not support organs and tissues when they are dissected and closed. This, like the transfer of sharp instruments from the operating sister to the surgeon and back through a special table, lends itself to a special training session. Wider use of special stapling devices when imposing anastomoses of hollow organs and suturing of soft tissues allows not only to standardize the technique of operation, but also to reduce the risk of injury to the hands with suture needles.

In the near future, as the possibilities of robotics increase, it will 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 instruments and devices. Initially, such apodactyl surgery was considered as a means of protecting the patient, but now it is equally possible to provide greater safety for the surgeon in this way.

In case of damage to the skin when operating or bandaging an infected patient, it is necessary to immediately treat the gloves with disinfectant solutions and remove them. Then squeeze the blood out of the wound and thoroughly wash your hands with soap and running water, treat them with 70% alcohol and lubricate the wound with 5% iodine solution. When a patient's blood gets on the skin of the surgeon's hands, it is advisable to immediately treat them for 30-60 with a tampon moistened with a skin antiseptic that is allowed for use (70% alcohol, iodopyron, chlorhexidine sterillium, octeniderm, octenisept, 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, goggles or protective shield and double gloves). Unfortunately, only 27% of medical personnel are aware of the measures that should be taken when there is a risk of infection from an infected patient as a result of injury during surgery, examinations and manipulations.

Specific prevention involves immunization in two versions - planned and emergency. Obligatory specific prevention is necessary for all students of medical universities and colleges before they begin practical training. In addition, it is advisable to vaccinate all medical workers upon admission to work. Routine preventive vaccination is carried out according to the standard scheme (0-1-6 months).

Unvaccinated medical workers after contact should be given the same day hepatitis vaccine simultaneously (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 (at least 6 IU) per 1 kg of body weight. The vaccination scheme is 0-1-2-6 months, better with control of hepatitis markers (not earlier than 3-4 months after the administration of immunoglobulin). If contact has occurred with a previously vaccinated health care provider, the Center for Disease Control (USA) recommends the immediate determination of the level of antibodies in a health care provider; if they are present (10 IU / l and above), prophylaxis is not carried out; in the absence, a booster dose of the vaccine and 1 dose of immunoglobulin or 2 doses of immunoglobulin are administered at 1 month intervals.

Emergency prophylaxis of HBV infection is carried out in case of the risk of infection and disease (getting damage with blood entering the wound or mucous membranes) according to the scheme of 0-1-2 months with revaccination after 12 months and is carried out against the background of the introduction of a specific immunoglobulin. This algorithm must be implemented within the first 2 days after receiving a microtrauma. Emergency specific prophylaxis is considered mandatory if the patient is recognized as HBs-positive and the doctor has not been vaccinated previously or the level of antibodies in him is insufficient for protection.

Unfortunately, the penetration of HS virus into the body can only be countered by a mechanical barrier, since the vaccine against this disease does not exist due to 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 received arguments using evidence-based medicine. The existing degree of protection of medical personnel from nosocomial infection with viral infections, unfortunately, has its limits. Additional duties, combining professions and part-time work, work at night, holidays and weekends, high psycho-emotional stress and significant static physical exercise significantly increase the risk of injury when working with infected patients. It is possible to agree that microtraumas of hands, as a rule, are unintentional, unexpected, therefore their frequency can be reduced only slightly. Experience shows that most often surgeons neglect the existing risk and therefore cannot influence it. Even if we assume that the risk of infection of the surgeon is insignificant, it is not enough to ignore. Therefore, the precautions described above against 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 substantiation. Профилактические мероприятия гепатита В предусматривают: • сбор дополнительного эпидемиологического анамнеза у больных, поступающих в отделения риска, из групп риска; • внимание к микросимптомам основного заболевания, которые могут маскировать симптомы гепатита В; • барьерное обследование поступающих пациентов из групп риска на маркеры вируса гепатита В и активность аланинаминотрансферазы (АлAT); • 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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