Blood exposure accident among medical students

Méd Mal Infect 2001 ; 31 : 537-43  2001 Éditions scientifiques et médicales Elsevier SAS. Tous droits réservés S0399-077X(01)00262-1/FLA

Original article

Blood exposure accident among medical students O. Meunier ∗ , N. de Almeida, C. Hernandez, M. Bientz Institut d’hygiène, faculté de médecine, 4, rue Kirschleger 67085 Strasbourg cedex, France (Received 5 September 2000; accepted 10 February 2001)

Summary Objective – We report the results of a survey among medical students in the Strasbourg medical school, including questions standard precautions, prevention of blood exposure accidents, methods usually applied, and circumstances of blood exposure accident they may have been victims of. Design – Anonymous questionnaire forms were handed out to second, third, and fourth year medical students. Results – Thirty per cent of third and fourth year student who already have an experience in clinical practice described blood exposure accident during their hospital training. Suture was the most frequent accident circumstance described (45%), blood drawing for gas measurement was the second (24%). Only 45% of these accidents were reported but serology control was performed in 71% of the cases. Students were questioned on the use of gloves during invasive medical care, 50% of them did not use any protective gloves. Sixty seven per cent of students resheathed needles, and only 30% personally disposed of needles in special containers. Conclusion – The incidence of blood-exposure accidents in hospital medical students is high. Measures should be rapidly implemented to inform and train students on prevention and to teach them safe technical procedures.  2001 Éditions scientifiques et médicales Elsevier SAS blood exposure accident / medical student / prevention

Résumé – Accidents d’exposition au sang chez les étudiants en médecine. Objectifs – Nous proposons les résultats d’une enquête réalisée chez les étudiants en médecine de Strasbourg à propos de leurs connaissances des précautions standard, leurs habitudes dans le domaine de la prévention des accidents d’exposition au sang (AES) et des AES dont ils ont éventuellement déjà été victimes. Patients et méthodes – Un questionnaire anonyme est remis aux étudiants en médecine des 2, 3 et 4es années du second cycle des études médicales, au cours de la réunion des choix de stage. Résultats – Trente pour cent des étudiants de DCEM 3 et 4 signalent avoir été victime d’un AES à l’occasion de soins qu’ils donnaient au cours d’un stage clinique. Les sutures sont à l’origine de la plupart de ces accidents (45 %) puis la ponction artérielle pour gaz du sang (24 %). Seulement 45 % de ces accidents sont déclarés, mais 71 % des étudiants feront une surveillance sérologique post exposition. Parallèlement, les étudiants sont interrogés sur le port de gants lors de la réalisation des gestes invasifs (près de 50 % n’en portent pas). Les aiguilles utilisées sont encore trop souvent recapuchonnées avant d’être éliminées (67 % des étudiants le font « toujours » ou « souvent ») et le conteneur à aiguille n’est utilisé que par 30 % des personnes interrogées. Conclusion – Les AES chez les étudiants sont particulièrement fréquents. Un effort d’information et de sensibilisation des étudiants en médecine est nécessaire afin que le geste technique sécurisé, tant pour le soignant que pour le patient, soit enseigné.  2001 Éditions scientifiques et médicales Elsevier SAS accident d’exposition au sang / étudiants en médecine / prévention

∗ Correspondence and reprints.

E-mail address: [email protected] (O. Meunier).

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Blood exposure accidents or BEA are defined by the April 1998 Ministry of Health bulletin as [1, 2] “any accidental exposure to blood or to a biological fluid contaminated by blood, including a cutaneous injury during an incision or injection, or a projection on mucosa or on a injured skin”. The risk is a possible transmission of blood-borne viruses, among which HIV and Hepatitis B and C viruses. These risks are assessed according to the nature of the biological product and the kind of lesion [2]. Furthermore, the ministry presents the principle of “standard precautions” as the necessity to consider the risk of virus transmission, whatever the serological status of the source patient [3]. Indeed, the serological status of patients as to one or the other of these three viruses is often unknown by the patient himself or may have changed. In fact, when the serological status is unknown, it is considered as positive until proved otherwise. To understand the necessity for this, the epidemiology of hepatitis C should be studied: 1% of the French population is infected by the virus, which corresponds to almost 500,000 people in France, but 25% ignore their serological status as to this virus. If to this is added that for 30% of these infected persons, the mode of virus acquisition is unknown, the utmost care is mandatory for any invasive procedure including a risk of viral transmission or for some non invasive procedures such as the projection of blood on a mucosa during delivery, or when coming in contact with a cutaneous excoriation in a bloody injury. The transmission risk of HCV by needle sticking, from an HCV positive source patient, is estimated at 4% [4] which is inferior to the transmission risk of HBV when the source person is AgHbs positive (25%) largely superior to the transmission risk of HIV under the same circumstances (0.32%) [2]. Even though numerous surveys on BEA are regularly carried out on physicians and nurses [5 – 8], healthcare students, among whom medical students in Medical Schools are not surveyed. Thus we thought it was necessary to collect data on BEA in this student population, to determine the circumstances of these accidents as well as the understanding and application of these standard precautions by students. We also think that this survey may raise the awareness for the BEA risk and that through the questions asked, it may give notions on management whether medical (evaluation of the risk and antiretroviral prophylaxis, serologic follow-up, for example), or administrative (declaring BEA).

POPULATION AND METHOD A questionnaire, written out according to the Keita-Perse et coll’s document [5], was handed out to medical students (Document 1) during their meeting for the choice of clinical training at the beginning of the University year.

A questionnaire was given to every student in DCEM2, DCEM3, DCEM4 (4th, 5th, and 6th year) at the beginning of the meeting and collected as soon as filled out. The survey was made in September 1999, on students having been through one (DCEM3) or two years (DCEM4) of clinical training-stage. Students in DCEM2 had only been through a “nursing” training session when the questionnaire was handed out. Promotions number 159 students in DCEM2, 160 in DCEM3, and 211 in DCEM4, for a total of 530 in the Strasbourg medical school that year. The questionnaire included 23 questions. Administrative data concerned the promotion level and the number of training sessions per medical specialty undergone since the beginning of medical studies. Data relative to the procedures usually practiced by the student and to the observance of standard precautions during invasive care giving was also studied. Several questions concerned blood exposure accidents: the number of BEA that a student had had, a description of the implicated procedure, the site of the training session where the accident had occurred, circumstances and action of the student, as well on the administrative level (declaration) than on the medical one (immediate steps taken for disinfection, further serologic surveillance). Finally, the questionnaire presented more general questions, such as the influence of knowing the patient’s serologic status on the observance of standard precautions, choosing the training session, or the student’s vaccination against hepatitis B. Answers to the questionnaires were collected with the Excel software and processed on the statistical level with the Epi Info software, version 6. After dichotomizing the quantitative variables, the relation between the various factors was studied with the Chi2 test or Fischer’s exact test when validation conditions for the Chi2 were not fulfilled.

RESULTS One hundred and twenty questionnaires filled out by DCEM2 students were collected, for a participation of 75.5%. But when reading the answers to question 23 asking for a free commentary on the pertinence of this survey, it was noted that DCEM2 students do not consider themselves at risk for BEA, most of them having never practiced invasive procedures whether within their training sessions, or during nursing duty which they might have made outside of the normal requirements for their studies. Indeed, at the beginning of the year, they have been through no clinical training session but only through a “nursing” training session during which they are not allowed to practice care procedures. Nevertheless, we will keep in mind that eight students, among DCEM2, reported having been victim of a BEA. The circumstances of the accident were: venous puncture (four times),

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lumbar puncture (three times), and “another puncture” (one time). Ninety three questionnaires filled out by DCEM3 students (for a participation of 58.1%) and 139 by DCEM4 students (for a participation of 65.8%) were returned. The survey was processed for the whole of the DCEM3 and DCEM4 students, given the previous remarks: thus for a total of 232 questionnaires, and a mean participation of 62.5%. Ninety two per cent of the students say they are vaccinated against hepatitis B, 3% are being immunized, but 1% has never received any vaccine dose, that is 2 or 3 people in this population especially exposed to contracting this infection. Finally, 4% of the students did not answer the question. Most students (67%) do not know about standard precautions and answer they have never heard anything about them, either during their studies or during their training sessions. We questioned the students on the observance of wearing gloves during healthcare giving. To perform an arterial puncture (arterial blood gas), procedure practiced “often” or “sometimes” by 99% of the surveyed students, wearing gloves is systematic only for 34% of the students, whereas 24 and 25% respectively wear them “sometimes” or “never”. Suturing is another procedure practiced by almost all students at this stage of their training. Gloves are then worn by 84%. Three per cent “never” wear any and 3% “sometimes”. Other technical procedures such as, come intramuscular, sub-cutaneous, or intradermal injections, are less often performed by students. To the question “Do you wear gloves when you perform one of these procedures?” the answer is “always” in only 13 to 17% of the cases, 10 to 11% answer “often”, 14 to 16% “sometimes”, but 45 to 46% answer “never”. For intravenous punctures, gloves are worn systematically in 31% of the cases. But 13% of the surveyed people never wear any, 17% only sometimes. Two other questions directly concerned the understanding and application of standard precautions, especially concerning the processing of pricking or cutting objects soiled by blood. For the question concerning the resheathing of used needles, 39% of the students pretended systematically or “often” resheathing needles, whereas only 35% seemed to have banned this dangerous procedure. For the question relative to the good use of a needle container, 40% of the students never bring their container close to the care giving site, 28% sometimes think about it, and only 17% do it systematically. A general reflection on the principle of standard precautions is suggested by questions 19 and 20. Knowing about the serologic status of the patient for this or that viral disease largely influences the students’decision to wear gloves: 71% answer YES when they are asked if the

Table I. Circumstances of blood exposure episodes. Number

%

Suture

32

45

Arterial puncture for blood gas

17

24

Intramuscular injection

2

3

Intravenous injection

5

7

Lumbar puncture

5

7

Other punctures

8

11

Not defined

2

3

71

100

Total

decision to wear gloves for a specific procedure is influenced by knowledge of the serologic status of the patient. Even if 28% of the students, while vaccinated against hepatitis B, have second thoughts about choosing some internships, most students do not choose a clinical training session according to the risk of professional contamination. The number of accidents for medical students having filled out the questionnaire reaches 45 for DCEM4 (32%) and 26 for DCEM3 (28%). The answers do not allow us to tell whether they are accidents having occurred over the past year or over the past two years for DCEM4 students. One third of the students have already had a BEA. Furthermore, 8, 4, and 1 students respectively report having had 2, 3, or 4 BEA during their training sessions. Sixty two per cent of these BEA occurred on the student’s usual training site and 35% during ward duty. The questionnaire does not permit to report the exact circumstances of the accident, nor in which service (medical or surgical) the accident occurred. The circumstances of occurrence, detailed in table I, show that suturing is a high-risk procedure for BEA (32 BEA out of 71) as well as performing arterial punctures for blood gas (17 BEA out of 71). More technical procedures grouped under “other punctures” in the questionnaire, were reported as being the reason for eight BEA. In our study, we do not note a significant difference between the risk of BEA for students who use needle containers and those who do not (p = 0.57). In the same way, students who “never” or “sometimes” resheath needles do not seem to get hurt more than those who resheath needles “always” or “often” (p = 0.11). If the two most frequent BEA are considered: – for BEA having occurred during suturing, there is no significant difference between the fact that a student has taken the habit to resheath or not needles (p = 0.16) or to use needle containers (p = 0.49). We note that BEA during suturing all occurred when students were systematically wearing gloves for this type of procedure;

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effectively not be at risk of transmission in 54 and 55% of the cases for hepatitis B and C respectively, and for 62% of the cases for HIV. Nevertheless, 71% of the students, whether they have reported the BEA or not, undergo a serologic assessment three months later.

DISCUSSION

Figure 1. Answers to questions on the handling of sharp objects soiled with blood.

– for BEA having occurred during blood gas assessment, there is no significant difference between the fact that a student was wearing gloves or not when performing this procedure (p = 0.45). But it seems less frequent when the student has taken the habit not to resheath needles (p = 0.07, close to significance) and usually uses needle containers (p = 0.02). Administrative reporting of BEA is made in only 55% of the cases, 41% of the injured students do not report the BEA (4% did not answer the question). When a report is made, it is almost always (92.3% of the cases) done within the 48 hours following BEA and generally to the ward’s physician. Occupational medicine and the reference services for HIV are rarely consulted at the time of the accident. The “non reporting” (29 cases) is usually supported by the notion of a non-risk source patient (12 times). In the other cases, it is by lack of information (six times), lack of motivation (six times) or time (four times). The serologic status of source patients for hepatitis viruses and for HIV, is not documented in 18 to 20% of the cases, unknown for the injured student 14 to 16% of the cases, positive once for HIV, four times for HBV, and ten times for HCV. Globally, the source patient would

BEA are especially frequent in medical students. Our results correlate to those of Keita-Perse et al. [5] since for DCEM4, they reported 37% of BEA and 24% for DCEM3 (32 and 28% respectively in Strasbourg). The training of students for hospital hygiene and individual prevention of BEA comes from many sources: theoretical lectures but also and especially practice during the nursing and clinical training sessions. In the first case, it is regrettable that this teaching is not supported by questions for the “Internat” (French residency competitive exam) because the students’presence at these lectures is weak. Practical training is usually done under the authority of nurses or head nurses who do not have enough time to train medical students, because in some cases they already have student nurses to deal with. The study of BEA and of their consequences being relatively recent, Senior physicians in the wards are not necessarily the best examples to follow, since they were given no specific training during their studies. In fact, statistics show the low interest of hospital physicians for prevention since only very few are protected against hepatitis B for example. An effort is thus mandatory to support the notion of “standard precautions”, precautions that need to be set up to protect the caregiver, his family, and his coworkers. Standard precautions should be applied for all contacts with blood or a biological fluid, whatever the patient’s status on blood-borne transmissible viruses. These precautions consist first in wearing gloves for any procedure which could bring the caregiver into contact with blood, to wear an over-surgical dress and protection glasses for any procedure in which blood or a biological fluid could be projected. One of the essential elements of standard precautions is the “non resheathing” of needles. When handling cutting or sharp objects, all procedures bringing together the operator’s hands or worse still, the hands of two different people (the operator and his assistant), present the risk of accident [9]. Resheathing is a typical example of a dangerous procedure. Even if our study does not specify the exact circumstances of BEA, it appears that resheathing remains a frequent procedure which should be banned when learning technical procedures. Our results are slightly better than those of Keita-Perse et al. [5] who made their survey in 1996. The difference certainly comes from a general awareness which generates an improved observance of safe procedures. Sullivan et al. survey [10] carried out on Birmingham medical students in

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Figure 2. Answers to questions on the use of gloves when giving care.

1999 seems to reflect this trend even if culture and teaching are different. The results to come of a French survey could confirm our hopes in this field. The non-resheathing of needles is linked to the mandatory use of a needle and cutting object container the

features of which are specified in the ministry bulletin DH/EM 1 N◦ 98-9548 [11]. Besides its maximal content that must be observed, it is evident that the container must be close to the place where care is given so as to prevent further dangerous handling of soiled sharp objects. This

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common sense measure is only very partially respected by our students. It is frequently observed in wards that the used needle is put on the care tray and that it is rapidly hidden by soiled compresses or other material to be disposed of, sorting being performed later, far from the patient, in the nurses’ office for example. The sorting of disposable products by a third party, who doesn’t know the contents of the tray, is a major mistake because of its highrisk level. Precautions are not understood or voluntarily not applied by students who change their behavior when they know or think they know about their patients’ serologic status. This attitude goes against the very principle and definition of standard precautions. It is common to assess the “avoidability” of BEA, but the interpretation of answers to a questionnaire makes this exercise difficult. Our questionnaire does not address the specific circumstances of the accident which are described in the questionnaire included in the ministry’s bulletin and used by the occupational medicine service in our hospital for every reported accident. Our objectives were a little different and only aimed at raising students’ concern by reading a more general questionnaire and trying to assess the importance of BEA in this specific population. Nevertheless, in our survey, procedures at the origin of BEA are mostly sutures for which students almost always wear gloves (84%) and performing arterial puncture for the assessment of blood gas. In the latter circumstance, gloves were worn only by half of the students (34% wore them systematically and 16% “often”). Furthermore, it is interesting to note that students, who readily use a needle container or who have banned resheathing from their procedures, report significantly less BEA than others. It seems that students who are aware of the danger of technical procedures they perform are less susceptible to BEA than others. This is good news since it allows thinking that the chronological filiation: information – awareness – induces the decrease of BEA, even if the delay between each step is relatively long. Concerning “avoidability” Bouvet et al. [12] report rates ranging from 30 to 70% in the reviewed surveys and 64% in Assery et al. survey [13]. The circumstances of occurrence that we describe are the same as those usually described in literature [5, 9, 10, 13 – 15]. We must recall that BEA also occurs when disassembling and cleaning soiled instruments, as well as during the handling of trash cans [14]. A decrease of BEA incidence for students may be expected when taking into account the progressive acquisition of professional experience, the increased number of training sessions and of procedures. But our results do not allow concluding on a possible decrease of BEA according to the year of study and thus to acquired “professional experience”. Another year of study may not represent a lot of professional experience, but usually, according to the literature, experience does not seem to be a factor modi-

fying the risk of BEA occurrence [15] as well for surgeons as for nurses. Habits and repeated procedures are extremely difficult to change [13], they were acquired by people to answer needs, such as rapidity and easy perfomability, without necessarily including the notion of safety. Hence, professional procedures must necessarily be taught while insisting on safety, both for the patient and practitioner, by using from the first courses, adapted protection and safety gear. It is regrettable that individual protections are considered as little compatible with the workload and emergency procedures, that their use is often cumbersome. So it is a new and double goal task for teachers, who must change their habits and teach good practice to their students, since the epidemiological situation of transmissible infections has considerably changed over the last few years. As of June 30, 1998, 42 cases of professional HIV infection had been reported in France [16] out of which 13 were confirmed, the others were presumed of professional origin. Since 1994, their incidence has been decreasing to only a few yearly cases: one case in 1994, none in 1995, two cases in 1996, and one case in 1997. The ministry bulletin DGS/DH N◦ 98/249, dated April 20, 1998 [2] describes the transmission risks of blood-borne viruses and asks hospital managers to set up a real prevention policy for BEA, along with the need to report accidents and the circumstances of occurrence, so as to better adapt preventive measures. Some healthcare institutes have already set up this report policy, Bouvet et al. [12] estimate the number of accidents per nurse around 0.3 to 0.4 per year. Indeed, 52% of questioned nurses, in the mentioned study, had been victims of BEA, by needlestick injury in most cases (85%). Surgeons are also frequently concerned since 0.5 to 2.7% needlestick injuries are reported per procedure. Cleveland et al. [15] estimate the number of BEA at three per year and per dentist, but note a progressive decrease of accidents in this area since 1986. Nevertheless, these BEA remain very frequent despite efforts made for information [13]. It is evident that reporting BEA constitutes a database allowing determining their circumstances of occurrence. This database can also be used as a reference for the choice of safety devices and gear. Reporting was made official by the ministry bulletin DGS/DH/DRT N◦ 99/680 dated December 8, 1999. It should also allow setting up care procedures taking into account the mandatory hospital quality and hygiene to prevent transmission of nosocomial infections and to insure the safety of healthcare personnel. Nevertheless, BEA are often not declared [9, 13], because of an under estimation of the risk and because of the very demanding procedure which includes serologic follow-up and a possible antiretroviral chemoprophylaxis. Reporting is synonymous, for the victim, of awareness of the risk to have contracted

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a chronic viral infection, with all its consequences, especially for private or personal life. This survey, such as we wished to carry out on medical students, allows to count BEA, the circumstances of occurrence, and the rate of administrative and clinical management. These results may be compared to further surveys carried out in the same circumstances, after setting up corrective measures in health care organization (availability of adapted gear), information of students and teachers, and installing a real policy of sensibilization. These results should push us to immediately reviewing the “initial lecture” of new students in the medical school, to asking the faculty to modify the contents of courses by insisting on the risks of BEA linked to their specialty, and to defining the general and eventually specific measures to be set up. The capital role of occupational medicine services in the health institutes must be taught to students so that they will know who to contact for vaccination against hepatitis B, but also in case of BEA for the report and for post exposure serologic surveillance. To raise the students’ awareness and to induce a personal reflection on the consequences of a BEA, we wrote out a question (question 18) relative to the possible modification of sexual behavior for a BEA victim expecting the results of serologic follow-up. It is difficult to assess the true impact of this question on student behavior who almost all answered “abstinence” or “condoms”. We hope this question will allow a better awareness of the risk raised by an irresponsible attitude. The participation rate of students in this survey was mediocre and reflects a low interest for a process even though concerning their safety. The Nice study [5] reports a participation rate of 84%. The questionnaire allowed a number of freely written out answers comforting us as to the interpretation of this rate.

CONCLUSION BEA are especially frequent in medical students. “Avoidability” is difficult to assess but knowing about and observing standard precautions are quite unsatisfactory and require a real information campaign. In hospital wards, nurses and assistant nurses are already aware of risks and have usually changed their habits: for a few years now, handling of blood and biological fluids has been performed with great caution. Nevertheless, physicians do not seem sufficiently informed or motivated yet to change what is often a risk behavior. Safety should be a daily concern, integrated in the training and learning of technical procedures, considering that it is very difficult to change a bad habit once acquired.

ACKNOWLEDGEMENTS Dean P. Gerlinger, Dean of the Strasbourg Medical School for his support to this study and to the Strasbourg University Hospitals within the convention signed with the University Laboratories.

REFERENCES 1 Circulaire DGS/DH N◦ 98/228 du 9 avril 1998 relative aux recommandations de mise en œuvre d’un traitement antirétroviral après exposition au risque de transmission du VIH. 2 Circulaire DGS/DH N◦ 98/249 du 20 avril 1998 relative à la prévention de la transmission d’agents infectieux vehiculés par le sang ou les liquides biologiques lors des soins dans les établissements de santé. 3 CTIN. Ministère de l’Emploi et de la Solidarité. Isolement septique, recommandations pour les établissements de soins. Paris: Edition du Service de l’Information et de la Communication; 1998. 4 Hamid SS, Farooqui B, Rizvi Q, Sultana T, Siddiqui AA. Risk of transmission and features of hepatitis C after needlestick injuries. Infect Control Hosp Epidemiol. 1999; 20: 63-4. 5 Keita-Perse O, Pradier C, Rosenthal E, Altave J, Cassuto JP, Dellamonica P. Les étudiants hospitaliers : une population à risque d’accidents d’exposition au sang (AES). Press Med 1998; 27: 17236. 6 Parneix P. Exposition cutanéo-muqueuse au sang. Concours Med 1999; 121: 1954. 7 Sicot C. Prévention de la contamination professionnelle par le VIH et le VHC. Concours Med 1997; 119: 2667. 8 Sistrom MG, Coyner BJ, Gwaltney JM, Farr BM. Frequency of percutaneous injuries requiring postexposure prophylaxis for occupational exposure to human immunodeficiency virus. Infect Control Hosp Epidemiol 1998; 19: 504-6. 9 Nelsing S, Nielsen TL, Nielsen JO. Noncompliance with universal precautions and the associated risk of mucocutaneous blood exposure among Danish physicians. Infect Control Hosp Epidemiol 1997; 18: 692-8. 10 Sullivan M, Masters O, Venkatesan. Needlestick injuries among medical students in Birmingham, UK. J Hosp Infect 2000; 44: 2401. 11 Lettre-circulaire DH/EM 1, N◦ 98-9548 du 1er septembre 1998 relative à la collecte des objets piquants et tranchants souillés. 12 Bouvet E, Tarantola A. Protection des personnels hospitaliers contre les risques d’accidents exposant au sang. Revue du Praticien 1998; 48: 1558-62. 13 Assery N, Alfandari S, Vandenbussche C, Guery B, Parent K, Georges H, et al. Analyse des pratiques et connaissances sur les accidents d’exposition au sang. Med Mal Infect 1998; 28: 612-7. 14 Bertrande S, Coupé P. Les accidents d’exposition au sang. Soins 1999; 633: 50-3. 15 Cleveland JL, Gooch BF, Lockwood SA. Occupational blood exposures in dentistry: a decade in review. Infect Control Hosp Epidemiol 1997; 18: 717-21. 16 Lemaire J. Infections professionnelles par le VIH en France chez le personnel de santé. Concours Med 1999; 121: 1922.