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Date Posted: 12:00:10 05/16/02 Thu
Author: Anonymous
Subject: Serologic Evaluation for Hepatitis B, Hepatitis C, and HIV-1

http://www.medscape.com/viewarticle/431452_print

Infection Control
Serologic Evaluation for Hepatitis B, Hepatitis C, and HIV-1 of Surgical Patients and Health Care Providers in a Urology Clinic

Bora Ozveren, MD, Orkunt Ayaz, MD, Tufan Tarcan, MD, Bulent Erkurt, MD, Levent Turkeri, MD, Atif Akdas, MD; Marmara University School of Medicine, Istanbul, Turkey

Infect Urol 15(1):3-7, 2002. � 2002 Cliggott Publishing, Division of SCP Communications
Abstract and Introduction
Abstract
A study of 720 urology patients demonstrates preoperative serology for hepatitis B surface antigen (HBsAg), antibody to HBsAg, antibody to hepatitis B core antigen, antibody to hepatitis C virus (HCV), and antibody to HIV-1. An identical voluntary screening was also done among health care workers in the urology department. The seroprevalence rate of viral hepatitis among patients undergoing urologic surgery was not higher than that of the general healthy population in the region. The screening of the urology health care workers revealed a prevalent hepatitis B virus (HBV) exposure rate and a higher seroprevalence of HBV carrier state and HCV infection, compared with the general population. The adherence to universal precautions should be emphasized among urology health care providers.

Introduction
Percutaneous exposure to hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV-1 represents an occupational risk to health care providers. Numerous seroepidemiologic studies of patients attending emergency, general surgery, and transplantation surgery clinics exist in the literature.1-3 Comparable data relating to patients from a urology clinic, however, are scarce.

The purpose of this investigation was to describe the seroprevalence and epidemiologic characteristics of HBV, HCV, and HIV-1 among patients scheduled for elective urologic surgery. We aimed to define the frequency of these viral markers and to assess the risk of infection associated with urology patients, as compared with the general population. In addition, we conducted a voluntary testing of HBV, HCV, and HIV-1 seroprevalence among a cohort of urologists, nurses, and operating room personnel in the urology department, whose occupations entailed frequent exposure to patients' blood and body substances.

In our view, the emphasis on informational and educational programs about reductions of infection risk needs to be specialty-specific. The data from this study, therefore, may aid in setting effective prevention priorities for urology departments and urology health care providers.

Patients and Methods
A total of 720 consecutive patients who were scheduled for elective surgery in the department of urology underwent blood testing preoperatively for the presence of hepatitis B surface antigen (HBsAg), antibody to HBsAg (anti-HBs), antibody to hepatitis B core antigen (anti-HBc), antibody to HCV (anti-HCV), and antibody to HIV-1 (anti-HIV-1). The screening of these viral markers was done in conjunction with other preoperative blood tests. This confidential screening was performed with the consent of the patients.

Patients were interviewed and examined for signs of hepatitis and sexually transmitted diseases. Variables recorded were sex, associated disease (liver disease, chronic kidney failure and hemodialysis, and coagulation disorders), history of blood products transfusion, and preoperative alanine aminotransferase (ALT) level. Five hundred forty-two patients were men, and 178 were women. The mean age was 49 (range, 16 to 81 years).

Identical serologic analyses were also performed, following informed consent, on samples from 26 health care providers who had been working in the urology department during the time span of this study. The cohort included 20 urologists, 2 scrub nurses, 3 scrub personnel, and 1 extracorporeal shock wave lithotripsy (ESWL) technician. The ESWL technician had also been involved in a variety of endourologic interventions and patient management in the operating room.

All serologic assays were performed in the hospital laboratories, which are audited by an internal quality control program. HBsAg, anti-HBs, and anti-HBc analyses were done by enzyme immunoassay technique (AUSAB; Abbott Laboratories, North Chicago), and HCV antibody was determined by microparticle enzyme immunoassay technique (Recombinant C200, C22-3, HC-34, HC-31, AxSYM; Abbott Laboratories, North Chicago). Latex aggregation test (Capillus HIV-1-1/HIV-1-2; Cambridge Diagnostics, Galway, Ireland) was used for anti-HIV-1 detection. Serum ALT measurements were done with a Dupont Dimension Kit (du Pont de Nemours Laboratory, Wilmington, Del). The reference interval of serum ALT was 35 to 60 U/L.

Results
Serologic evidence of exposure to HBV (by infection or active immunization) was found in 42.3% (305/720) (Table 1 ). Anti-HBs and/or anti-HBc was detectable in 40.1% of the study group (289/720). Of the patients exposed to HBV, the seroprevalence rate of antibodies to HBV (anti-HBc and/or anti-HBs) was 94.8% (289/305). Concurrent seropositivity for anti-HBc and anti-HBs was detected in 93.2% of the HBV-exposed patients, indicating postinfectious immunity in this group. Five percent (16/305) of HBV-exposed patients had HBs antigenemia, displaying HBV carrier status. Overall, HBsAg positivity was demonstrated in 2.2% of the urology patients.

Anti-HCV was found in 9 patients (1.3%), who all had simultaneous positive serology for antibodies to HBV. Four of the HCV-positive individuals had been in a hemodialysis program, while the routes of transmission were obscure in the rest. Thus, after excluding the patients who had been on dialysis, the prevalence of anti-HCV in the remaining group was 0.7% (5/716).

None of the patients had positive serology for HIV-1. Four patients had a history of transfusion of blood products. Only 2 of these patients had been exposed to HBV. No patients admitted a history of intravenous drug use.

Serum ALT levels were above normal in 52 patients. In 11 (21%) of these patients, ALT levels were more than 3 times the upper limit of normal. This significantly high preoperative level of ALT was 100% correlated to seropositivity of viral markers in our study group; HBV infection was demonstrated in 3 and HCV in 8 of these patients. One of the patients with HBsAg and 3 of those with anti-HCV presented with clinical evidence of possible liver disease (jaundice, hepatomegaly, or ascites). There were no clinical findings of infection in the rest of the seropositive patients.

History of chronic kidney failure requiring hemodialysis and high (above 3 times the upper limit of normal) preoperative liver enzyme levels emerged as factors that predicted positive results, especially for hepatitis C. Serologic testing of this group of patients only would have detected 89% of the HCV-positive cases.

The screening of the health care providers revealed a serologic status indicating past HBV infection in 3 (15%) of the 20 urologists. One had a history of clinically overt HBV infection that was succeeded by HCV infection 1 year later. Both anti-HBs and anti-HBc indicating postinfectious immunity were detected in the other 2 surgeons, who denied any history of clinical HBV infection. Of the remaining urologists, 70% (14/20) had postvaccination immunity for HBV and, lastly, 3 surgeons were negative for all serologic markers.

One scrub nurse had postvaccination immunity to HBV, whereas the other had active immunization subsequent to a clinical HBV infection. Two of the scrub personnel had postinfectious immunity, and the third demonstrated an HBV carrier state. The ESWL technician had also been immunized to HBV after vaccination. The serologic screening of the health care providers revealed that 62% (16/26) were passively immunized (postvaccination), whereas 23% (6/26) were actively immunized (postinfectious) to HBV. One was an HBV carrier, and 3 were negative for HBV.

Antibodies to HCV were not found in any of the operating room personnel or nurses (Table 2).

Discussion
Urology patients. This seroprevalence study revealed HBsAg in 2.2%, anti-HBs and anti-HBc in 40.1%, and anti-HCV in 1.3% of patients undergoing urologic surgery. The HBsAg seroprevalence in this group represents one of the lowest rates compared with the majority of the serologic surveys of "healthy" blood donors or volunteers in our geographic region. The HBsAg prevalence among nonrisk populations is generally reported to be about 5%, although it ranges widely from 2% to 10% in various regions of Turkey.4-6 Yet, positive serology for both HBsAg and anti-HBs should be taken into account in assessing the seroprevalence rates in epidemic regions, such as Turkey. The anti-HBs prevalence is estimated to be as high as 23.8% to 48% and occurs at higher rates in less developed regions of the country.4 The 40.1% rate of HBV exposure in patients scheduled for urologic surgery evidently reflected Turkey as a country where HBV infection is moderately endemic. The 5% incidence of HBs antigenemia among the HBV-exposed urology patients represents the major occupational risk for health care providers.

The 1.3% HCV seroprevalence rate in the study group is comparable to that of the corresponding general population. HCV infection occurs at a rate of 0.31% to 1.5% among the nonrisk population in this country and is more prevalent in persons who are older and of lower socioeconomic status.7 In a regional study, the anti-HCV prevalence was determined as 0.31% among healthy blood donors, whereas 5.4% of prostitutes, 33.4% of hemodialysis patients, and 57.6% of intravenous drug abusers were positive.8

The absence of HIV-1 infection among our patients is in accord with the current serosurveillance studies in this country, suggesting that HIV-1 has not yet been widely introduced into the general population.9,10

The different epidemiologic patterns of HBV and HCV account for the geographic heterogeneity of the seroprevalence rates. The overall age-adjusted prevalence of HBV infection was reported as 4.9% in the United States.11 The rate of HBV antibodies was 6.9% and HBV antigenemia was 0.7% in the Flemish population, whereas the respective rates were 12.8% and 3% in a subpopulation of immigrants to Israel from the former USSR.12,13

In a seroprevalence study among patients undergoing major surgery, the HBsAg, anti-HCV, and anti-HIV-1 rates (1.4%, 5.2%, and 1.6%, respectively) were found to be higher than in the general population of the areas studied (Valhalla, NY, and Barcelona, Spain).14,15 On the other hand, in the United States, seropositivity rates were 5% for HBsAg, 18% for anti-HCV, and 6% for anti- HIV-1 among patients admitted to an emergency department,1 and the rate of anti-HBs positivity in trauma patients was reported as 20%.3 In another study (Ankara, Turkey) designed to estimate the occupational risk of blood-borne infections among urologists, positive serology for HBV and/or HCV was found in 47.4% of 300 urology patients, among whom the rate of antigenemia was 9.9%.16

The routes for contamination cannot be described in 20% to 40% of hepatitis C cases, although a higher rate of transmission is associated with repeated transfusions, transplantation, hemodialysis, cardiac surgery, and frequent hospitalization.17,18 In our study, the mode of transmission could not be determined in 56% of HCV-positive patients. After exclusion of the patients on dialysis programs, the prevalence of anti-HCV in the rest of the group was calculated as 0.7%. Obviously, a history of transplants, hemodialysis, and frequent blood transfusions carries a significant risk of HCV seropositivity in this group of patients in a urology clinic. In our study, none of the patients for whom blood transfusions were the source of hepatitis C had a history of urologic surgery.

Health care workers in a urology department. Among the urologists, postinfectious immunity was demonstrated in 15% and postvaccination immunity in 70%. Twenty-seven percent (7/26) of the health care workers in this department had serologic findings of past HBV infection, which entailed active immunization in 86% (6 with postinfectious immunity and 1 with HBV carrier state). Although the study cohort was small, the HBV carrier state (3.7%) and HCV infection (3.7%) were more frequent among health care providers, in contrast to the patient group. All health care workers who had been passively immunized after hepatitis B vaccination were documented to have maintained active HBsAg status. Our results are not necessarily representative of all hospitals in Turkey, but they are presumed to be similar in many teaching institutions in inner-city areas.

In addition to the geographic variances of infection prevalence, the procedural skills of health care workers and the frequency of invasive versus noninvasive procedures affect the exposure risk and will be different between institutions. The risk of contamination with infected material during surgery is higher for residents and attending surgeons, and diminishes in an orderly fashion from scrub nurse to technician to anesthesiologist.19 In a study investigating the exposure ratio for needle stick accidents or other exposure during 1 academic year, surgery residents were found to be at 6 times greater risk for exposure, compared with internal medicine residents. As would be expected, the surgery residents encountered 60% of these incidents in the operating room.20

Conclusions
As a consequence of these observations, indiscriminate screening of patients for viral hepatitis and HIV-1 infection has been abandoned in our urology department. These tests are now performed when there are pertinent clinical findings; when there is a history of blood transfusions, chronic renal disease, hemodialysis, transplantation, or elevated serum ALT levels; and on demand of the patient.

The voluntary screening of health care workers has provided a reasonably precise documentation of the dimension of occupational risk of infection in our department. All urology surgeons, nurses, and medical personnel with negative serology for HBV were prompted to receive vaccination, and the implementation of and strict adherence to the guidelines of universal precautions have once again been underscored for all health care providers in our department.21

Our study provides essential data on seroprevalence of HBV, HCV, and HIV in patients undergoing elective surgery in a urology clinic. In this specific setting, the patients scheduled for surgery are not a higher-risk group than the general healthy population in Turkey. While the actual risk to health care professionals cannot be determined with complete accuracy, it is apparently subject to alterations based on the prevalence of infections in various geographic regions and the range of the surgical practice. Therefore, we believe that such seroepidemiologic studies in different settings and medical practices are key to defining the particular occupational risks and to appreciating the imperative measures necessary for the prevention of blood-borne infections. It is also recognized that a known or documented risk is more likely to be considered seriously -- and managed appropriately.

Tables
Table 1. Serologic Screening of Viral Markers for HBV, HCV, and HIV-1 Infections Among 720 Urology Patients

Marker Number of patients (%)
All (2) 415 (57.7)
HBsAg (+) 16 (2.2)
Anti-HBc (+) and/or anti-HBs (+) 289 (40.1)
Anti-HCV (+) 9 (1.3)
Anti-HIV-1 (+) 0 (0)

HBV, hepatitis B virus; HCV, hepatitis C virus; HBsAg, hepatitis B surface antigen; anti-HBc, antibody to hepatitis B core antigen; anti-HBs, antibody to HBsAg.

Table 2. Aggregated Frequency of Serologic Markers for HBV Infection in 26 Health Care Providers

Marker Number of patients (%)
HBsAg (+) 1 (3.7)
Anti-HBc (+) and/or anti-HBs (+) 22 (84.6)
Anti-HCV (+) 1 (3.7)
Anti-HIV-1 (+) 0 (0)

HBV, hepatitis B virus; HBsAg, hepatitis B surface antigen; anti-HBc, antibody to hepatitis B core antigen; anti-HBs, antibody to HBsAg; HCV, hepatitis C virus.

References

1. Kelen GD, Green GB, Purcell RH, et al. Hepatitis B and hepatitis C in emergency department patients. N Engl J Med. 1992;326: 1399-1404.
2. Degos F, Lugassy C, Degott C, et al. Hepatitis B virus and hepatitis B-related viral infection in renal transplant recipients: a prospective study of 90 patients. Gastroenterology. 1988;94:151-156.
3. Caplan ES, Preas MA, Kerns T, et al. Seroprevalence of human immunodeficiency virus, hepatitis B virus, hepatitis C virus, and rapid plasma reagin in a trauma population. J Trauma. 1995;39:533-537.
4. Doganci L, Haznedaroglu T. Prevalence of hepatitis A, B and C in Turkey. Eur J Clin Microbiol Infect Dis. 1992;11:661-662.
5. Cakaloglu Y, Okten A, Yalcin S. Seroepidemiology of hepatitis B infection in Turkey. Turk J Gastroenterohepatol. 1990;1:49-53.
6. Kuru U, Senli S, Turel L, et al. Age-specific seroprevalence of hepatitis B virus infection. Turk J Pediatr. 1995;37:331-338.
7. Thomas DL, Mahley RW, Badur S, et al. The epidemiology of hepatitis C in Turkey. Infection. 1994;22:411-414.
8. Yenen OS, Badur S. Prevalence of antibodies to hepatitis C virus in blood donors and risk groups in Istanbul, Turkey. Eur J Clin Microbiol Infect Dis. 1991;10:93-94.
9. Cetin ET. The studies for fight against AIDS in Turkey. Fight against AIDS Association: Fight against AIDS 1. In: Program and abstracts of the Turkish Congress; January 12-15, 1993; Istanbul, Turkey. Abstract 48.
10. Yilmaz G, Badur S, Cetin ET. Seroprevalence of HIV infection among people attending the HIV/AIDS Diagnostic Laboratory for HIV antibody test since 1985 in Istanbul. II. European Meeting on Migratory Prostitution; March 29-April 1, 1994; Istanbul, Turkey:30.
11. McQuillan GM, Coleman PJ, Kruszon-Moran D, et al. Prevalence of hepatitis B virus infection in the United States: the National Health and Nutrition Examination Surveys, 1976 through 1994. Am J Public Health. 1999;89:14-18.
12. Beutels M, Van Damme P, Aelvoet W, et al. Prevalence of hepatitis A, B and C in Flemish population. Eur J Epidemiol. 1997;13:275-280.
13. Almog R, Low M, Cohen D, et al. Prevalence of anti-hepatitis A antibodies, hepatitis B viral markers, and anti-hepatitis C antibodies among immigrants from the former USSR who arrived in Israel during 1990-1991. Infection. 1999;27:212-217.
14. Montecalvo MA, Lee MS, DePalma H, et al. Seroprevalence of human immunodeficiency virus-1, hepatitis B virus, and hepatitis C virus in patients having major surgery. Infect Control Hosp Epidemiol. 1995;16:627-632.
15. Santiveri X, Matute E, Escolano F, et al. Prevalence of viral hepatitis in candidates for orthopedic surgery. Rev Esp Anestesiol Reanim. 1995;42:417-419.
16. Oge O, Ozen H, Oner S, et al. Occupational risk of hepatitis B and C infections in urologists. Urol Int. 1998;61:206-209.
17. Chung H, Lee JS, Lok AS. Prevention of posttransfusion hepatitis B and C by screening for antibody to hepatitis C virus and antibody to HBcAg. Hepatology. 1993;18:1045-1049.
18. Mele A, Sagliocca L, Manzillo G, et al. Risk factors for acute non-A, non-B hepatitis and their relationship to antibodies for hepatitis C virus: a case-control study. Am J Public Health. 1994;84:1640-1643.
19. Tokars JI, Bell DM, Culver DH, et al. Percutaneous injuries during surgical procedures. JAMA. 1992;267:2899-2904.
20. O'Neill TM, Abbott AV, Radecki SE. Risk of needlesticks and occupational exposures among residents and medical students. Arch Intern Med. 1992;152:1451-1456.
21. Centers for Disease Control. Guidelines for prevention of transmission of human immunodeficiency virus and hepatitis B virus to health-care and public safety workers. MMWR. 1989;38(suppl S-6):1-37.

Dr Ozveren is a fellow, Dr Ayaz is a resident, Dr Tarcan is an associate professor, Dr Erkurt is a fellow, Dr Turkeri is a professor, and Dr Akdas is a professor in the department of urology at Marmara University School of Medicine in Istanbul, Turkey.

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