Speaker : Dr.

Akshat Goel
(Junior Resident - 1)

Moderated By : Dr. Arun Vashisht

(Assistant Professor)

AIDS was diagnosed in 1981 in several patients with disease complexes previously seen only in patients with immunodeficiencies of known causes. After the diagnosis of AIDS, HIV was identified and was found to cause this disease complex. Two strains of HIV have been identified:

HIV-1, which is the strain most common in the United States HIV-2, which has been reported primarily in Europeans, West Africans in Europe, and rarely in the United States.

HIV, a human RNA retrovirus. This group of RNA viruses has the ability to produce reverse transcriptase, which converts RNA to DNA and incorporates into the host chromosome. The HIV retrovirus is trophic for the CD4 surface receptors of Tlymphocytes. The virus causes deregulation and destruction of these T lymphocytes, ultimately resulting in an immuno-deficient state, with progressive decline in the number of circulating CD4 lymphocytes over several years. When the CD4 cell count is less than 200/mm3, opportunistic infections occur, and clinical manifestations of AIDS begin.

Acute primary HIV infection appears clinically similar to infectious mononucleosis and occurs 2 to 6 weeks after viral transmission. This stage is Self Limiting. Within 3 months after viral transmission, most patients develop positive serology, and virtually all patients seroconvert by 6 months, although delayed sero-conversion 1 year after infection has also been reported. After acute infection, a symptomless prolonged period ranging from 5 to more than 15 years is observed this is a Chronic asymptomatic stage of HIV infection. In the third stage the patient is no longer symptom free but has not yet developed AIDS defining opportunistic infections as defined by the CDC or an absolute CD4 cell count of less then 200/mm3 In the final stage, a potentially life-threatening opportunistic disease develops as a result of the severe cell-mediated immunodeficiency. The CD4 cell count below 200/mm3 leading

Sexual Route (Vaginal, Anal , Oral)

Heterosexual Homosexual

Parentral Route (Blood Contact)

Blood transfussion Intravenous drug use Occupational exposure (Needle stick, cuts, splashes)

Maternal Infant route (Mother to child)

In-utero During delivery Breast feeding

Other Confirmatory Tests

Antigen detection test In-situ Hybridization test Indirect Immuno-Flouroscence essay Radio-Immuno Precipitation Essay Polymerase Chain Reaction Test (PCR)

The CD4 lymphocyte count is not a diagnostic test but rather a measurement of the degree of immuno-suppression. Because the serological tests currently used for the detection of HIV depend on the formation of antibodies by the infected patient, there is a period of time known as the Window Period during which the patient is infectious before the appearance of the HIV antibodies. Most patients (approximately 99%) develop antibodies to HIV within 6 months of the initial infection, but delayed seroconversion (after 1 year) has been reported. Reliance on a single test may give a false sense of security.

The management of patients with HIV / AIDS has reached all fields of medicine. The orthopaedic surgeon may be required to treat HIV-positive patients in the emergency department, clinic, or operating room. Because of this increasing likelihood, the orthopaedist should know the causes, associated diseases affecting the musculoskeletal system, the risks of transmission, and precautions in regard to this infection.

The most common musculoskeletal syndromes in HIV-infected patients are manifestations of

Drug toxicity Reactive arthritis Infectious arthritis Myositis Tendinitis Bursitis

Any musculoskeletal syndrome that occurs in nonHIV-infected patients can occur in HIV-infected patients but the HIV infection may alter the clinical presentation, severity, and course of musculoskeletal problems and therefore early diagnosis of infections is especially important to prevent their spread in an immuno-compromised patient. Reactive Arthritis usually occurs in the foot and ankle. Tendinitis involving the Achilles tendon and the anterior and posterior tibial tendons is common. Septic arthritis occurs more commonly in intravenous drug abusers and haemophiliacs who have become infected with HIV.

Primary osteomyelitis has been reported in HIV-infected patients, but usually it is the result of direct extension from a septic joint. An HIV-infected patient with a total joint prosthesis may be at an increased risk for infection as immuno-suppression progresses. Muscle pain or myositis is a common complaint in HIV-infected patients, including idiopathic polymyositis, polymyositis secondary to zidovudine toxicity and pyomyositis. Idiopathic polymyositis and zidovudine polymyositis patients complain of muscle weakness and have elevated creatine phosphokinase (CPK) levels. Pyomyositis, usually caused by S. aureus, can present as a solitary abscess or multiple abscesses within the muscle.

The risk of orthopaedic surgeons contracting HIV infection from patients is unknown at this time. In 1991, Tokars et al. surveyed 3420 orthopaedic surgeons who reported performing more than 9000 procedures on patients known to be HIV-infected. Of these, only 2 (0.06%) tested positive for HIV antibody. A 1995 CDC report of occupationally acquired HIV infection in health care workers (HCW) listed no documented occupational transmission in surgeons, and only four cases were listed as being possibly transmitted occupationally. Emanuel described three factors that must be known to calculate the orthopaedic surgeon's risk of incurring HIV from punctures in the operating room

The frequency of punctures The percentage of surgical patients who are HIV-positive The risk of HIV transmission per needle stick from known HIV-positive patients.

At the end of 2004, it was estimated by the World Health Organization that approximately 39.4 million people worldwide were infected with

In the United States, it has been estimated that 0.5% of the population is HIV-positive with approximately 25% of positive patients unaware of their HIV infection. The exact prevalence of HIV-infected patients in a specific surgeon's practice is impossible to calculate without prospective testing; however, it has been reported to be 10%, with regional and local variations. By 1997, 94 cases of documented occupational HIV infection in health care workers had been reported worldwide, and approximately 170 additional cases had a possible occupational etiology for HIV infection. Most (87.2%) were related to a single percutaneous needle stick. Lemaire and Masson noted that 6% to 50% of operations result in at least one blood contact between patient and health care worker, and 1.3% to 15.4% of procedures involve a sharp injury. Risk decreased with surgical experience, but increased with operative time. Fitch et al. found that the greatest risk for occupational transmission of HIV involved parenteral injection of blood through orthopaedic pins or hollow core needles. No cases of transmission from solid core needles has been documented.

Risk increases with increased viral load of the patient, quantity of blood injected, and depth of inoculation. Based on data obtained by the American Board of Orthopaedic Surgeons, the estimated puncture rate for the orthopaedic attending physician is 2.8%, averaging approximately 10 punctures a year. The risk of transmission per needle stick has been estimated by the CDC to be approximately 0.3%. These figures put the annual risk to the orthopaedic surgeon between 0.025% and 0.5%, a cumulative (>40 years of practice) risk of 0.6%. The area most commonly injured by needle sticks is the volar aspect of the index finger and the thumb of the non-dominant hand. Suture needles cause 85% of these injuries. In orthopedics and trauma surgery there has been concern about aerosols containing blood from the power instruments used for drilling, reaming or sawing, and of the danger from bone chips contacting the surgeons eye. These risks are theoretical. There is no biological or epidemiological evidence that HIV can be transmitted by aerosols entering the respiratory tract.

In the absence of an effective means of prophylaxis, including a vaccine, the chief defense against HIV infection is the prevention of its transmission. Health care workers at risk are those most prone to sustain needle sticks, cuts, and skin tears in the presence of contaminated body fluids and tissues. The cases of HIV transmission through wounds underscore the importance of infection control procedures, especially in the operating room.

Routine preoperative screening for transmissible diseases such as HIV has been suggested so that special precautions can be taken, but there are arguments against this. HIV testing requires informed consent and this is not possible when the patient is not conscious. For patients requiring emergency operations the results of HIV testing are not available in time. Routine HIV testing is negative during early infection and before seroconversion. Preoperative HIV screening is now agreed not to be costeffective and precautions should apply to every surgical procedure, not selectively for patients known or suspected to be HIV-positive. The CDC, however, recommends routine screening for HIV, with informed consent, for patients between 15 and 54 years of age in regions of high HIV Prevalence. Patients known to be at risk for HIV should also be tested, with their consent. Any selection of patients on this basis is a sensitive matter; AIDS activists, the media and politicians may object to what they consider is arbitrary discrimination.

A number of precautions, to be applied universally, were recommended by the CDC in 1987 to prevent contact with blood, or other body fluids and tissues. These recommendations were published by the AAOS in 1989 and new guidelines were introduced in 1996. An effective barrier between the patient and the surgical team requires appropriate protective draping and garments of non-woven, impervious materials; towel clips should not be used. The surgical gown should be reinforced over the sternum, abdomen and forearms for trauma surgery. Masks and surgical hoods, also of nonwoven material, should provide extended coverage, and impermeable boots should be

The routine use of protective glasses (Wrap around eye wears) or facial shields integrated with a mask or helmet is advised despite their relative discomfort: projection of blood or aerosols of blood cause 3% to 5% of contaminations. Gloves must be worn whenever contact with blood is anticipated. Any defects in gloves or per-operative perforations may cause prolonged contact with the patients blood. Double gloving reduces the risk of contact from 29% to 18%, but the outer pair should be changed at least every two hours, or every hour for trauma surgery. Gloves reinforced with Kevlar or polyester/stainless-steel wire weave liners are designed to reduce perforations of the inner glove, but provide variable protection and variable comfort. They should be considered when bone fragments are to be manipulated or sharp instruments or saws are in use. Indicator gloves can also be used to alert the surgeon to

The rules for surgical technique:

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Avoid the use of sharp instruments when possible. Avoid direct passing of sharp instruments between team members. Use a no-touch technique. Use a scalpel for skin incisions only, then scissors and electrocautery. Avoid simultaneous suture of the same layer by two members of a team. Prefer to use blunt suture needles. Avoid hasty gestures. Comply with regulations for the elimination of disposable material. Always wear gloves when handling material covered with blood. Proper post operative scrubbing

In addition, all high-risk procedures should be reviewed to identify the specific hazards for each team member and to develop better reduction of risk.

Efficacy of universal precautions. The efficacy of universal precautions is uncertain, and the attitude to them depends largely on the perception of danger.

Wash hands after patient contact, removing gloves Wash hands immediately if hands contaminated with body fluids Wear gloves when contamination of hands with body substances anticipated All HCWs should take precautions to prevent injuries during procedures and when cleaning or during disposal of needled and other sharp instruments Needle should not be recapped Needles should not be purposely bent or broken by hand, nor removed from disposable syringe or manipulated by hand After use disposable syringes and needles, scalpel blades and other sharp items should be placed in a puncture resistant container. Health care workers who have exudative lesions or dermatitis should refrain from direct patient care and from handling equipment. Handle and dispose of sharps safely. Clean & disinfect blood / body substances spills with appropriate agents. Adhere to disinfection and sterilization standards. Regard all waste soiled with blood / body substance as contaminated and dispose of accordingly to relevant standards.

HIV is a fragile virus and susceptible to heat and is killed by

Boiling

Only for few minutes

Chemical disinfection

Minimum contact time 30 mins 0.5% to 1.0% sodium hypochlorite (bleach solution) 70% Ethanol 2% gluteraldehyde Povidone Iodine Formalin 3-4%

An exposure that may place an Health Care Provider (HCP) at risk of blood bourne infection is defined as a percutaneous injury (e.g. needle prick or cut with a sharp instrument), contact with the mucous membranes of the eye or mouth, contact with non-intact skin (particularly when the exposed skin is chapped, abraded, or afflicted with dermatitis), or contact with intact skin when the duration of contact is prolonged with blood or other potentially infectious blood fluids. Body fluids that are potentially infectious include blood, semen, vaginal secretions, CSF, synovial pleural, peritoneal, pericardial and amniotic fluids or other body fluids contaminated with visible blood. Exposure to tears, sweat, urine, faeces, saliva of an infected person is normally not considered as an exposure unless these secretions contain visible blood. Data from HIV surveillance of health-care workers shows that by September 1997, 94 cases of documented occupational HIV infection of health-care workers had been reported worldwide, with a further 170 cases of possible occupational HIV infection.

Most infections (87.2%) followed a single percutaneous injury, usually a needlestick, but the injury was caused by a scalpel in two cases and by an orthopaedic pin in another. Eight infections occurred after mucocutaneous exposure to blood or to concentrated HIV; two cases had both percutaneous and mucocutaneous exposure to blood. Some cases probably go unreported and unregistered by the passive surveillance systems; 10% to 60% of percutaneous injuries are not registered being considered as too trivial or because of lack of awareness of the reporting procedure, deliberate avoidance of reporting for reasons of confidentiality or fear of professional implications. Monitoring of HIV prevalence in health-care personnel may give a better evaluation, with an insight into unreported and unregistered seroconversion.

After Accidental exposure to blood (or body fluids containing blood)

Wash wound immediately with running tap water and soap. Document occupational accident. Confidential counseling and testing of source for HIV. Evaluation of risk of infection and transmission. Consult with and refer to nearest resource for post-exposure prophylaxis, evaluation and follow-up.

Don'ts

Do not panic! Do not reflexively place pricked finger into mouth. Do not squeeze blood from wound, this causes trauma and inflammation, increasing risk of transmission. Do not use bleach, alcohol, betadine or iodine, which may be caustic, also

causing trauma.

Dos

Remove gloves, if appropriate. Wash site thoroughly with running water. Irrigate with water or saline, if eye or mouth. Use soap, if skin wound.

HIV chemoprophylaxis

Based on evaluation or wound and source, start the appropriate course of post-exposure therapy. Ideally, prophylaxis should be begun within 2 hours of exposure. In controversy never delay start of therapy, start with 2-drug regimen and change on expert advise.

Timing and Duration of HIV PEP

Start PEP as soon as possible after an exposure, preferably within 2 - 24 hours. After 71 hours, expected efficacy is minimal. Administer PEP for 4 weeks. A repeated HIV test by enzyme immunoassay of the exposed individual should be performed at 6 weeks, 12 weeks and 6 months post-exposure, regardless of whether or not PEP was taken. An exposed person taking PEP should be advised to use precautions (e.g. avoid blood or tissue donations, breastfeeding, unprotected sexual contact or pregnancy) to prevent secondary transmission.

E xposure
Mucous membrane / non-intact skin; small volume (drops) Mucous membrane / non-intact skin; large volume (major blood splash) Percutaneous exposure; not severe, solid needle, superficial Percutaneous exposure; severe, Large bore hollow needle, deep injury, visible blood in device, needle in patient artery/vein

S tatus of source H +and H +and IV IV H status IV lowrisk hig risk h unknown

Usually no PEP, consider 2 - drug PEP Usually no PEP, 2 - drug PEP 3 - drug PEP consider 2 - drug PEP Usually no PEP, 2 - drug PEP 3 - drug PEP consider 2 - drug PEP 2 - drug PEP 2 - drug PEP 3 - drug PEP 3 - drug PEP Usually no PEP, consider 2 - drug PEP

In theory, there is a risk of transmission of HIV from surgeon to patient but it is very small. Six patients were reported to have been infected by one dental surgeon in Florida, but the circumstances of the contamination are obscure. Mathematical models of direct transmission from healthcare workers to patients suggest that the risk is extremely low. With a surgeon known to be HIVseropositive, the risk of reverse transmission of HIV to the patient is about 1 chance in 83 000 hours of surgery. For invasive procedures performed by surgeons of unknown HIV status, the risk of transmission of HIV from surgeon to patient has been estimated at 1 chance per 21 million hours of surgery with an upper-bound 95% risk of 1 in 4 million.44 This would imply that it is not justified to restrict the work of persons infected with HIV.