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Global challenges with BBV transmission in health

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Lecture on global challenges with BBV transmission in health by Prof. Shaheen Mehtar during the 6th International Infection Control Conference 2006

Lecture on global challenges with BBV transmission in health by Prof. Shaheen Mehtar during the 6th International Infection Control Conference 2006

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Global challenges with BBV transmission in health Global challenges with BBV transmission in health Presentation Transcript

  • Global challenges with BBV transmission in health Prof Shaheen Mehtar, Academic Unit for IPC, Centre for Infectious Diseases Tygerberg Academic Hospital & Stellenbosch Uni,
  • BBV & unsafe injections
    • Model for transmission through unsafe injections annually (WHO)
      • HBV 8-16 m
      • HCV 2.3- 4.7 m
      • HIV 160 000
    • Highest number of recorded unsafe injection were in Asia and Sub-Saharan Africa
    • 1.6 m deaths associated with unsafe injection
    • Diseases transmissible by NSI 58.3%
    • Reason for unsafe injection practice
      • Inadequate provision 27%
      • Poverty 18.3%
      • Ignorance 18%
      • Improper disposal 17.2%
      • Lack of supervision of HCW 11.8%
      • Negligence 8%
    Injection safety knowledge: West Africa Ernet SK. West Afr J Med, 2002. 21; 70-3
  • Recycling injection equipment- Pakistan
    • Dumping used syringes into community waste- 59%
    • Municipal waste- 7%
    • Reselling used syringes- 9%
    • Housekeeping staff reselling syringes -88%
    Mujeeb SA et al. ICHEpi. 2003. 24; 145
    • Health waste dealers trade
      • Scavengers
      • Housekeeping staff from Health Centres
    • Syringes further sold to
      • Plastic industry
      • Recycled used syringe to the public
      • Cleaned and repackaged for sale on the open market
    Recycling injection equipment- Pakistan (2)
  • Knowledge among HCP- China
    • Questionnaire to nurses (53.06%) & doctors (46.3%)
    • Poor knowledge of HIV 90%
    • Fear of caring for HIV patients- 24%
    • Contracting HIV from fomites such as toilet seats, breathing the air in a patient’s room
    • 27% did not believe NSI was a relevant source for BBV
    • 11% would resheath needles to prevent spread.
    Andersen, AF, Qingsi Z, Guanglin Wu et al. 2003 ICH Epi
  • Survey of HCW on NSI- UK
    • Knowledge of risk of transmission post NSI was
    • HBV 44%
    • HCV 54.6%
    • HIV 54.6%
    • Nurses Doctors
    • All patients as potentially BBV 86% 41%
    • Hand washing good poor
    • re-sheathing needles never often
    • NSI with used needle less more
    • NOT reporting NSI 2% 28%
  • Unsafe injections-Pakistan (1)
    • Practice among general practitioners in a peri-urban area
    • Interviewed clients and took blood samples (67%) for BBV
    • 135 adults agreed to be tested
      • 81% received injection on that day
      • 44% & 19 % respectively positive for HCV and HBV
    Khan AJ et al. Bull WHO,2000.78(*)
  • Unsafe injections-Pakistan (2)
    • Practitioner knowledge survey (n=18)
      • None knew HCV could be transmitted via injection
    • Practitioner practice
      • 94% of injections given with previously used needles and syringes.
    • Average of 10 injections per year in 72% of patients in 1994.
  • Recycling injection equipment- Pakistan
    • Dumping used syringes into community waste- 59%
    • Municipal waste- 7%
    • Reselling used syringes- 9%
    • Housekeeping staff reselling syringes -88%
  • Improper use of sharps
    • Multi-dose vial, pre loaded syringe, blood sample syringe, loading a syringe with saline, next to an ICU patient’s bed.
  • HCV associated with Multi-dose vials- USA
    • HCV – acute infection within 8 weeks of hospitalization
    • 41 patients hospitalised during that week
    • 24 (59%) participated in the study
    • HCV genotype 1b found in 5 patients
    • 3 of 4 received saline flushed from a multi-dose vial were HCV positive
    • 9 patients who did not, were HCV negative
  • Needle-less system Save usage of a multi dose vial with a needle-less system and an non return valve
  • Clinic settings
    • Inadequate protection
    • Use of multi-dose vials used for vaccination
    • Inadequate number of injections and syringes
    • Poor waste discard
      • Lack of segregation
      • Lack of sharps disposal
      • No legislative support
    Cape Times, Nov 2005
  • Sharps disposal in clinics- SCK 1999
  • Waste disposal in Developing Countries
    • Don’t know how much waste is generated in hospitals
    • Legislation exists but is not implemented
    • Segregation of waste not taken seriously
    • Waste disposal inadequate and often dumped in open land fill areas
  • Category of staff as a %age TBH
  • NSI- 1999 to 2005 by speciality
  • Inexpensive intervention
    • Moved sharps container closer to point of generation
    • Reduced NSI from 35 to 2/month over 3 month (ongoing)
  • Source Blood- HIV increase from 16% to 23%
  • Cost of needle stick injuries NNU
  • Risks in Dentistry-
    • Aerosol, blood spray and NSI major risks
    • Reuse of anaesthetic vial between patients
    • Items left exposed and reused on following patients have a risk of transmission
    • Reuse of items without proper sterilization are of risk to the patients.
  • Other practices
    • Delivery in hospital or by traditional birth attendants
    • Reuse of non-sterile vaginal speculae due to lack of supplies
    • Poor cleaning and disinfection of laryngeal masks
    • Outbreaks associated with endoscopes reported from Australia, UK, USA, France with HBV & HCV. One HIV
    • Challenge tests show removal of all test BBV with 2% glut for 20 min in hysteroscopy set
    • But clinical circumstances different- short time between patients
    • 60% of endoscopy recycling unsatisfactory
    Endoscopy and BBV
  • Gastroscopes- Japan
    • HCV rates of 23.4% those undergoing gastroscopy
    • Inadequate number of gastroscopes
    • Use of 2%-3% glut for cleaning was adequate to prevent transmission.
  • Scarification & Tattooing- SA
    • Traditional ritual by traditional healers
      • No known means of disinfection
      • All items re-used
    • Tattooing in Correctional Services
      • 54% juveniles (>21 years) HBV positive
      • 58% juveniles had been tattooed in prison
      • Among adult females = 9% HBV +
  • CS tattooing Transmission rate of HBV = 32% juveniles
  • Problems highlighted in developing countries
    • IC of low profile , not many doctors involved. Mainly nurse driven
    • Lack of IC knowledge among health care deliverers- Need IPC courses to understand
    • Lack of application of IC – Standard Precautions
    • Lack of, or irregular, supplies
    • Lack of legislation to ensure good practice
    • Urgently need for active IC programmes
  • Education and Training in IPC
    • The best prevention strategy is knowledge
    • To understand risk and how to deal with it
    • Even the poorest countries can improve safety for both patients and staff
  • Conclusion
    • Transmission of BBV does occur in HCF
    • The extent is unknown but possibly can account for 5% of hepatitis B, C and HIV transmission
    • With good infection control, almost ALL is preventable
    • IC measures show immediate cost effective outcome