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Birthing pools and infection control
THE LANCET
showed three-vessel coronary artery disease and was treated by balloon angioplasty and stent implantation. The antithrombotic regimen consisted of ticlopidine once daily 250 mg and aspirin once daily 80 mg. 10 days later the plasma creatinine had risen from 139 to 325 µmol/L. Aspirin was continued and ticlopidine was stopped. After 2 weeks the creatinine had returned to the baseline value. Since our patient was also taking aspirin, we can only conclude that renal side-effects of ticlopidine may be important, perhaps by a mechanism analogous to that involved in the renal side-effects of non-steroidal antiinflammatory drugs. The promising results obtained by the combination of ticlopidine and aspirin, to reduce the incidence of stent thrombosis, are currently leading to widespread use of ticlopidine. We suggest that renal function is monitored during ticlopidine treatment.
scrubbing of the whole inside and top of the pool with hypochlorite (Milton 1 in 10 dilution) and leaving on for 30 min, followed by thorough rinsing off, would inactivate even hepatitis B virus. However, prolonged use might damage the metal parts of the birth pool, such as waste pipes. We would only be able to accept the use of a birthing pool with an approved cleaning protocol together with the exclusion of mothers known to be HIV, hepatitis B, or hepatitis C positive. *A P C H Roome, R C Spencer *Pubic Health Laboratory, Bristol Royal Infirmary, Bristol BS2 8HW, UK
1 2
P Elsman, *F Z ijlstra De Weezenlanden Hospital, Department of Cardiology, 8011 JW Z wolle, Netherlands
1
2
3
Fischman DL, Leon MD, Baim DS, et al. A randomized comparison of coronary-stent placement and balloon angioplasty in the treatment of coronary artery disease. N Engl J Med 1994; 331: 496–501. Serruys PW, de Jaegere P, Kiemeneij F, et al. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease. N Engl J Med 1994; 331: 489–95. Serruys PW, Emanuelsson H, van der Giessen W, et al. Heparincoated Palmaz-Schatz stents in human coronary arteries: early outcome of the Benestent II PIlot Study. Circulation 1996; 93: 412–22.
Birthing pools and infection control SIR—The difficulties experienced by Ridgway and Tedder (April 13, p 1051)1 reflect our concern about the microbiological safety of birthing pools. First, addressing the risk of blood-borne viruses, the risks of HIV-1 and HIV-2 are the lowest. If a needlestick injury from infected blood has a seroconversion rate of only 0·3%, the dilution factor even from a large bleed from these labile viruses would make the infection risk very small. The risk from hepatitis C is higher, since the virus is more stable than HIV and the needlestick injury infection rate is about 2–3%. Hepatitis B risk is of a different order of magnitude. This is an extremely resistant virus that survives water, and in an e antigen positive, chronically infected patient, the virus attains high blood levels. With all these viruses, perinatal transmission from mother to baby is important, and even the small risk of HIV or hepatitis C transmission from mother to baby and the staff is unacceptable. It is difficult to see how a case can be made for not screening mothers for all three viruses and excluding any positives. Second, faeco-orally transmitted viruses such as enteroviruses (ECHO and Coxsackie) and adenoviruses, which also infect by the conjunctival route, can all cause severe illness in neonates. In this case it would be more likely that subsequent mother and baby pairings, rather than the index pair, would suffer, since in a perinatal infection of the mother with any of these agents, the baby would be likely to be infected from the mother even without delivery in a birthing pool. There is also concern about the transmission of bacterial pathogens either from skin (methicillin-resistant Staphylococcus aureus and Streptococcus pyogenes) or anus (Salmonella spp or Campylobacter spp). Studies have shown that the addition of antiseptics, such as sodium hypochlorite, to pool water has proved effective in eliminating bacterial pathogens.2–4 With regard to cleaning the pool after use, thorough
274
3
4
Ridgway GL, Tedder RS. Birthing pools and infection control. Lancet 1996; 347: 1051–52. Smith RF, Blasi D, Dayton SL, Chips DD. Effective sodium hypochlorite on the microbial flora of burns and skin. J Trauma 1974; 14: 938–44. Cardany CR, Rodeheaver GT, Horowitz JH, Kenny JG, Edlich RE. Influence of hydrotherapy and antiseptic agents on burn wound bacterial contamination. J Burn Care Rehabil 1985; 6: 230–32. Steve L, Goodhart P, Alexander H. Hydrotherapy burn treatment: use of chloramine-T against resistant microorganisms. Arch Phys Med Rehabil 1979; 60: 301–03.
SIR—Positively Women provides peer support to women living with HIV. We have worked with over 800 women since 1993. Although we acknowledge the medical benefits to mother and child of knowing their HIV status, we know from our experience of supporting women tested positive for HIV in antenatal settings that an HIV diagnosis is a traumatic experience—especially if the woman does not consider herself to have been at risk (which is often the case). To ask a pregnant woman to go through such an experience for health and safety rather than medical reasons does not seem to us to be appropriate treatment of that patient or appropriate health and safety practice. We support the view of Department of Health’s Expert Advisory Group On AIDS that “where there is a lack of confidence that thorough decontamination can be achieved testing should not be used to mitigate against perceived lack of safety of the equipment”.1 They also note that “Health and Safety Law would require alternative arrangements to be made if any workplace equipment was unsafe”.1 The Department of Health’s Changing Childbirth2 promotes choice for pregnant women. We believe that HIVpositive pregnant women, and pregnant women untested for HIV, have the same needs in their mode of delivery as women tested negative for HIV. We question, therefore, if it is acceptable and ethical for women who have opted not to have an HIV test, or who are known to be HIV positive, to be denied their choice of a birthing pool when it is otherwise available to other pregnant women. The decision to take an HIV test must be voluntary (this is Department of Health policy) and we would argue that a test in such circumstances (ie, where a birth pool is denied otherwise) is coercive and possibly a breach of patients’ rights. We wonder also what HIV testing of pregnant women would achieve. Each woman would need to be tested twice in order to establish her status outside a possible “window period”. This may not be possible if the timing is not right. Decontamination procedures should cover the possibility of HIV. Stephanie Elsy Positively Women, 347–49 City Road, London EC1V 1LR, UK
1 2
Letter from Baroness Cumberlege to Lord Kilmarnock, Chair of the All Party Parliamentary Group for AIDS, April 1, 1996. Expert Maternity Group. Changing childbirth. August, 1993.
Vol 348 • July 27, 1996
showed three-vessel coronary artery disease and was treated by balloon angioplasty and stent implantation. The antithrombotic regimen consisted of ticlopidine once daily 250 mg and aspirin once daily 80 mg. 10 days later the plasma creatinine had risen from 139 to 325 µmol/L. Aspirin was continued and ticlopidine was stopped. After 2 weeks the creatinine had returned to the baseline value. Since our patient was also taking aspirin, we can only conclude that renal side-effects of ticlopidine may be important, perhaps by a mechanism analogous to that involved in the renal side-effects of non-steroidal antiinflammatory drugs. The promising results obtained by the combination of ticlopidine and aspirin, to reduce the incidence of stent thrombosis, are currently leading to widespread use of ticlopidine. We suggest that renal function is monitored during ticlopidine treatment.
scrubbing of the whole inside and top of the pool with hypochlorite (Milton 1 in 10 dilution) and leaving on for 30 min, followed by thorough rinsing off, would inactivate even hepatitis B virus. However, prolonged use might damage the metal parts of the birth pool, such as waste pipes. We would only be able to accept the use of a birthing pool with an approved cleaning protocol together with the exclusion of mothers known to be HIV, hepatitis B, or hepatitis C positive. *A P C H Roome, R C Spencer *Pubic Health Laboratory, Bristol Royal Infirmary, Bristol BS2 8HW, UK
1 2
P Elsman, *F Z ijlstra De Weezenlanden Hospital, Department of Cardiology, 8011 JW Z wolle, Netherlands
1
2
3
Fischman DL, Leon MD, Baim DS, et al. A randomized comparison of coronary-stent placement and balloon angioplasty in the treatment of coronary artery disease. N Engl J Med 1994; 331: 496–501. Serruys PW, de Jaegere P, Kiemeneij F, et al. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease. N Engl J Med 1994; 331: 489–95. Serruys PW, Emanuelsson H, van der Giessen W, et al. Heparincoated Palmaz-Schatz stents in human coronary arteries: early outcome of the Benestent II PIlot Study. Circulation 1996; 93: 412–22.
Birthing pools and infection control SIR—The difficulties experienced by Ridgway and Tedder (April 13, p 1051)1 reflect our concern about the microbiological safety of birthing pools. First, addressing the risk of blood-borne viruses, the risks of HIV-1 and HIV-2 are the lowest. If a needlestick injury from infected blood has a seroconversion rate of only 0·3%, the dilution factor even from a large bleed from these labile viruses would make the infection risk very small. The risk from hepatitis C is higher, since the virus is more stable than HIV and the needlestick injury infection rate is about 2–3%. Hepatitis B risk is of a different order of magnitude. This is an extremely resistant virus that survives water, and in an e antigen positive, chronically infected patient, the virus attains high blood levels. With all these viruses, perinatal transmission from mother to baby is important, and even the small risk of HIV or hepatitis C transmission from mother to baby and the staff is unacceptable. It is difficult to see how a case can be made for not screening mothers for all three viruses and excluding any positives. Second, faeco-orally transmitted viruses such as enteroviruses (ECHO and Coxsackie) and adenoviruses, which also infect by the conjunctival route, can all cause severe illness in neonates. In this case it would be more likely that subsequent mother and baby pairings, rather than the index pair, would suffer, since in a perinatal infection of the mother with any of these agents, the baby would be likely to be infected from the mother even without delivery in a birthing pool. There is also concern about the transmission of bacterial pathogens either from skin (methicillin-resistant Staphylococcus aureus and Streptococcus pyogenes) or anus (Salmonella spp or Campylobacter spp). Studies have shown that the addition of antiseptics, such as sodium hypochlorite, to pool water has proved effective in eliminating bacterial pathogens.2–4 With regard to cleaning the pool after use, thorough
274
3
4
Ridgway GL, Tedder RS. Birthing pools and infection control. Lancet 1996; 347: 1051–52. Smith RF, Blasi D, Dayton SL, Chips DD. Effective sodium hypochlorite on the microbial flora of burns and skin. J Trauma 1974; 14: 938–44. Cardany CR, Rodeheaver GT, Horowitz JH, Kenny JG, Edlich RE. Influence of hydrotherapy and antiseptic agents on burn wound bacterial contamination. J Burn Care Rehabil 1985; 6: 230–32. Steve L, Goodhart P, Alexander H. Hydrotherapy burn treatment: use of chloramine-T against resistant microorganisms. Arch Phys Med Rehabil 1979; 60: 301–03.
SIR—Positively Women provides peer support to women living with HIV. We have worked with over 800 women since 1993. Although we acknowledge the medical benefits to mother and child of knowing their HIV status, we know from our experience of supporting women tested positive for HIV in antenatal settings that an HIV diagnosis is a traumatic experience—especially if the woman does not consider herself to have been at risk (which is often the case). To ask a pregnant woman to go through such an experience for health and safety rather than medical reasons does not seem to us to be appropriate treatment of that patient or appropriate health and safety practice. We support the view of Department of Health’s Expert Advisory Group On AIDS that “where there is a lack of confidence that thorough decontamination can be achieved testing should not be used to mitigate against perceived lack of safety of the equipment”.1 They also note that “Health and Safety Law would require alternative arrangements to be made if any workplace equipment was unsafe”.1 The Department of Health’s Changing Childbirth2 promotes choice for pregnant women. We believe that HIVpositive pregnant women, and pregnant women untested for HIV, have the same needs in their mode of delivery as women tested negative for HIV. We question, therefore, if it is acceptable and ethical for women who have opted not to have an HIV test, or who are known to be HIV positive, to be denied their choice of a birthing pool when it is otherwise available to other pregnant women. The decision to take an HIV test must be voluntary (this is Department of Health policy) and we would argue that a test in such circumstances (ie, where a birth pool is denied otherwise) is coercive and possibly a breach of patients’ rights. We wonder also what HIV testing of pregnant women would achieve. Each woman would need to be tested twice in order to establish her status outside a possible “window period”. This may not be possible if the timing is not right. Decontamination procedures should cover the possibility of HIV. Stephanie Elsy Positively Women, 347–49 City Road, London EC1V 1LR, UK
1 2
Letter from Baroness Cumberlege to Lord Kilmarnock, Chair of the All Party Parliamentary Group for AIDS, April 1, 1996. Expert Maternity Group. Changing childbirth. August, 1993.
Vol 348 • July 27, 1996