- Email: [email protected]
Routine preprocedure testing of patients in Japan for bloodborne pathogens?
204
letters to the Editor
Vol. 35 No. 3
Table 1. Reports of infections/risk of infection associated with barbers’ shops and hairdressing salons
Organism
Year
Customer or hairdresser/ barber infected
Mycobacterium tuberculosis
2006
Hepatitis B
Patient details
Description
Reference
Hairdresser
41-Year-old female hairdresser of Brazilian origin
3
2005
Customers
Five patients in a nursing home
Methicillin-resistant Staphylococcus aureus
2001
Potential cross-infection risk for patients from hospital hairdresser
nil
Microsporum canis
2001
2 Female customers
2, 71-year-old women
An antecubital abscess was surgically treated at another institution, and there was good initial wound healing. Swelling then recurred, and fistulae appeared in the scar. Subsequent diagnostic workup revealed an isolated intramuscular tuberculous abscess, which was successfully treated by an antituberculous drug regimen. From December 2002 to April 2003, 5 residents with acute hepatitis B infection were identified with an attack rate of 5.5% and a case fatality rate of 40%. Other potential risk factors were undergoing podiatric care and being exposed to the shared razor blade of the hairdresser. Homes to prevent bloodborne pathogens. Analysis of hospital hairdresser’s procedures and decontamination practices confirmed her to be a potential source. Swabbing of her equipment after a day’s session with her normal cleansing practice revealed the presence of MRSA, confirmed by phage typing as an epidemic strain within the hospital. This provided putative evidence for a vehicle of transmission. Two elderly women presented to the dermatology clinic within 8 weeks of each other, with scalp scaling and alopecia. In both cases, Microsporum canis grew on fungal culture of their hair and required prolonged treatment with terbinafine. Neither of them gave a history of contact with young children or any animals. Both were fairly fit and not systemically immunocompromised. However, both had been regularly visiting the same hairdresser, during the presumed period of infectivity, making this the most likely source of infection. A cross-sectional epidemiologic survey was conducted in the Casablanca region during 2001 among 150 barbers, all men. It included a medical-social questionnaire and a serology workup (HIV, HCV, HBV, TPHA, VDRL). The subjects’ mean age was 36.5 6 14.7 years, they had worked in the trade for an average of 17.8 6 8.7 years, and the socioeconomic status of most was low. Hygiene conditions were deficient. The concept of infectious risk associated with blood was generally not well-known, especially for hepatitis B and C; most were not vaccinated. HIV serology was negative for all barbers. Syphilis serology was positive for 7% by TPHA and for 4% by VDRL. HBV was positive in 2% and HCV in 5%.
HIV, HBV, HCV, syphilis
4
5
6
7
HBV, hepatitis B virus; HCV, hepatitis C virus; TPHA, Treponema pallidum hemagglutination assay; VDRL, venereal disease research laboratory test.
6. Takwale A, Agarwal S, Holmes SC, Berth-Jones J. Tinea capitis in two elderly women: transmission at the hairdresser. Br J Dermatol 2001; 144:898-900. 7. Zahraoui-Mehadji M, Baakrim MZ, Laraqui S, Laraqui O, El Kabouss Y, Verger, et al. Infectious risks associated with blood exposure for traditional barbers and their customers in Morocco. Sante 2004;14:211-6. doi:10.1016/j.ajic.2006.10.010
Routine preprocedure testing of patients in Japan for bloodborne pathogens? To the Editor: I recently had the opportunity to teach residents at several hospitals in Japan. During my visit, I was told
that almost all hospitals in Japan routinely check the hepatitis B, hepatitis C, and syphilis status on hospitalized patients and patients having surgery or invasive procedures, such as coronary angioplasty. To my surprise, the rationale for checking for these diseases is to ‘‘protect’’ the physicians, nurses, or other health care workers who have direct contact with patients. The prevailing belief in Japan is that health care workers will be more ‘‘careful’’ during surgeries or procedures if they know the patient is positive for the above 3 infectious diseases. I find that this belief and practice contrasts sharply from evidence-based practice here in the United States. I feel that it can also be potentially dangerous to health care workers. In the United States, we do not routinely
letters to the Editor
check for potential bloodborne diseases before procedures because we regard every patient as potentially infectious and take extra precautions to avoid injuries during procedures. In fact, this tenet (universal precautions), has been incorporated into regulations, and specifically, in its 1987 document, ‘‘Recommendations for the Prevention of HIV Transmission in Health-Care Settings,’’1 the Centers for Disease Control and Prevention states the following: ‘‘Since medical history and examination cannot reliably identify all patients infected with HIV or other bloodborne pathogens, blood and body-fluid precautions or Ôuniversal precautionsÕ should be used in the care of all patients, especially those in emergency care settings in which the risk of blood exposure is increased and the infection status of the patient is usually unknown.’’ In Japan, health care workers are only encouraged to receive hepatitis B vaccines, and, for those who choose to receive the vaccine, the cost is usually split between the employee and the hospital. No matter how accurate the blood tests are, there will be some false-negative results because of window periods, and no test kit is 100% sensitive. If patients need emergency surgery or procedures, there is no time to await results of these blood tests, and the idea of no positive test results means no infectious disease can be hazardous to health care workers. Therefore, in Japan, the health care workers may have a false sense of security and be ‘‘less careful’’ when dealing with patients who test negative. As explained above, I feel that routinely screening the general asymptomatic public for syphilis, hepatitis B, and hepatitis C infection can be hazardous to health care workers. It is not cost-effective and, furthermore, can cause potential harm to patients because of labeling and discrimination. Therefore, the US Prevention Service Task Force does not recommend this practice.2
April 2007
205
As in the United States, Japanese patients need to sign a consent form before they can be tested for HIV. Few Japanese citizens are willing to be tested for HIV, so HIV testing is not routinely included in the preop blood tests. According to the latest statistics,3 the number of HIV-positive patients in Japan has reached over 10,000, which is approximately 1/100 of the total number of HIV patients in the United States. Because Japanese people will be discriminated against in society if he or she is known to be HIV positive,4 this number could be ‘‘just the tip of the iceberg.’’ Therefore, a surgeon in Japan could potentially be operating on an HIV-positive patient who is assumed to be free of this bloodborne pathogen. This kind of false assumption can have disastrous consequences. For the safety and benefit of both patients and health care workers, I earnestly hope that hospitals in Japan will abandon this practice of screening and offer free hepatitis B vaccinations to all health care workers and practice standard precautions. Tze Shien Lo, MD Infectious Disease Section VA Medical Center Fargo, ND E-mail: [email protected]
References 1. Recommendations for prevention of HIV transmission in health-care settings. MMWR Morb Mortal Wkly Rep 1987;36(Suppl 2):S1-18. 2. US Preventative Services Task Force. Guide to clinical prevention services. 2nd ed. Washington, DC: Office of Disease Prevention and Health Promotion; 1996. 3. UNAIDS Joint United Nations Programme on HIV/AIDS Web Site. Available at: http://www.unaids.org/Regions_Countries/Countries/japan. asp. Accessed April 2005. 4. Sesser S. Hidden death. New Yorker 1994;70:62-70. doi:10.1016/j.ajic.2006.09.012
letters to the Editor
Vol. 35 No. 3
Table 1. Reports of infections/risk of infection associated with barbers’ shops and hairdressing salons
Organism
Year
Customer or hairdresser/ barber infected
Mycobacterium tuberculosis
2006
Hepatitis B
Patient details
Description
Reference
Hairdresser
41-Year-old female hairdresser of Brazilian origin
3
2005
Customers
Five patients in a nursing home
Methicillin-resistant Staphylococcus aureus
2001
Potential cross-infection risk for patients from hospital hairdresser
nil
Microsporum canis
2001
2 Female customers
2, 71-year-old women
An antecubital abscess was surgically treated at another institution, and there was good initial wound healing. Swelling then recurred, and fistulae appeared in the scar. Subsequent diagnostic workup revealed an isolated intramuscular tuberculous abscess, which was successfully treated by an antituberculous drug regimen. From December 2002 to April 2003, 5 residents with acute hepatitis B infection were identified with an attack rate of 5.5% and a case fatality rate of 40%. Other potential risk factors were undergoing podiatric care and being exposed to the shared razor blade of the hairdresser. Homes to prevent bloodborne pathogens. Analysis of hospital hairdresser’s procedures and decontamination practices confirmed her to be a potential source. Swabbing of her equipment after a day’s session with her normal cleansing practice revealed the presence of MRSA, confirmed by phage typing as an epidemic strain within the hospital. This provided putative evidence for a vehicle of transmission. Two elderly women presented to the dermatology clinic within 8 weeks of each other, with scalp scaling and alopecia. In both cases, Microsporum canis grew on fungal culture of their hair and required prolonged treatment with terbinafine. Neither of them gave a history of contact with young children or any animals. Both were fairly fit and not systemically immunocompromised. However, both had been regularly visiting the same hairdresser, during the presumed period of infectivity, making this the most likely source of infection. A cross-sectional epidemiologic survey was conducted in the Casablanca region during 2001 among 150 barbers, all men. It included a medical-social questionnaire and a serology workup (HIV, HCV, HBV, TPHA, VDRL). The subjects’ mean age was 36.5 6 14.7 years, they had worked in the trade for an average of 17.8 6 8.7 years, and the socioeconomic status of most was low. Hygiene conditions were deficient. The concept of infectious risk associated with blood was generally not well-known, especially for hepatitis B and C; most were not vaccinated. HIV serology was negative for all barbers. Syphilis serology was positive for 7% by TPHA and for 4% by VDRL. HBV was positive in 2% and HCV in 5%.
HIV, HBV, HCV, syphilis
4
5
6
7
HBV, hepatitis B virus; HCV, hepatitis C virus; TPHA, Treponema pallidum hemagglutination assay; VDRL, venereal disease research laboratory test.
6. Takwale A, Agarwal S, Holmes SC, Berth-Jones J. Tinea capitis in two elderly women: transmission at the hairdresser. Br J Dermatol 2001; 144:898-900. 7. Zahraoui-Mehadji M, Baakrim MZ, Laraqui S, Laraqui O, El Kabouss Y, Verger, et al. Infectious risks associated with blood exposure for traditional barbers and their customers in Morocco. Sante 2004;14:211-6. doi:10.1016/j.ajic.2006.10.010
Routine preprocedure testing of patients in Japan for bloodborne pathogens? To the Editor: I recently had the opportunity to teach residents at several hospitals in Japan. During my visit, I was told
that almost all hospitals in Japan routinely check the hepatitis B, hepatitis C, and syphilis status on hospitalized patients and patients having surgery or invasive procedures, such as coronary angioplasty. To my surprise, the rationale for checking for these diseases is to ‘‘protect’’ the physicians, nurses, or other health care workers who have direct contact with patients. The prevailing belief in Japan is that health care workers will be more ‘‘careful’’ during surgeries or procedures if they know the patient is positive for the above 3 infectious diseases. I find that this belief and practice contrasts sharply from evidence-based practice here in the United States. I feel that it can also be potentially dangerous to health care workers. In the United States, we do not routinely
letters to the Editor
check for potential bloodborne diseases before procedures because we regard every patient as potentially infectious and take extra precautions to avoid injuries during procedures. In fact, this tenet (universal precautions), has been incorporated into regulations, and specifically, in its 1987 document, ‘‘Recommendations for the Prevention of HIV Transmission in Health-Care Settings,’’1 the Centers for Disease Control and Prevention states the following: ‘‘Since medical history and examination cannot reliably identify all patients infected with HIV or other bloodborne pathogens, blood and body-fluid precautions or Ôuniversal precautionsÕ should be used in the care of all patients, especially those in emergency care settings in which the risk of blood exposure is increased and the infection status of the patient is usually unknown.’’ In Japan, health care workers are only encouraged to receive hepatitis B vaccines, and, for those who choose to receive the vaccine, the cost is usually split between the employee and the hospital. No matter how accurate the blood tests are, there will be some false-negative results because of window periods, and no test kit is 100% sensitive. If patients need emergency surgery or procedures, there is no time to await results of these blood tests, and the idea of no positive test results means no infectious disease can be hazardous to health care workers. Therefore, in Japan, the health care workers may have a false sense of security and be ‘‘less careful’’ when dealing with patients who test negative. As explained above, I feel that routinely screening the general asymptomatic public for syphilis, hepatitis B, and hepatitis C infection can be hazardous to health care workers. It is not cost-effective and, furthermore, can cause potential harm to patients because of labeling and discrimination. Therefore, the US Prevention Service Task Force does not recommend this practice.2
April 2007
205
As in the United States, Japanese patients need to sign a consent form before they can be tested for HIV. Few Japanese citizens are willing to be tested for HIV, so HIV testing is not routinely included in the preop blood tests. According to the latest statistics,3 the number of HIV-positive patients in Japan has reached over 10,000, which is approximately 1/100 of the total number of HIV patients in the United States. Because Japanese people will be discriminated against in society if he or she is known to be HIV positive,4 this number could be ‘‘just the tip of the iceberg.’’ Therefore, a surgeon in Japan could potentially be operating on an HIV-positive patient who is assumed to be free of this bloodborne pathogen. This kind of false assumption can have disastrous consequences. For the safety and benefit of both patients and health care workers, I earnestly hope that hospitals in Japan will abandon this practice of screening and offer free hepatitis B vaccinations to all health care workers and practice standard precautions. Tze Shien Lo, MD Infectious Disease Section VA Medical Center Fargo, ND E-mail: [email protected]
References 1. Recommendations for prevention of HIV transmission in health-care settings. MMWR Morb Mortal Wkly Rep 1987;36(Suppl 2):S1-18. 2. US Preventative Services Task Force. Guide to clinical prevention services. 2nd ed. Washington, DC: Office of Disease Prevention and Health Promotion; 1996. 3. UNAIDS Joint United Nations Programme on HIV/AIDS Web Site. Available at: http://www.unaids.org/Regions_Countries/Countries/japan. asp. Accessed April 2005. 4. Sesser S. Hidden death. New Yorker 1994;70:62-70. doi:10.1016/j.ajic.2006.09.012