All right - first off, I don't think we should use HIV+ patients in these hypotheticals. Just for the sake of edification - getting infected with HIV by an exposure from a patient is really unlikely. Even getting jabbed by a used needle is pretty low-risk (barring certain circumstances). Plus, since they use anti-retroviral prophylaxis nowadays, the risk is even lower.
Yes, the risk is low. The risk of Speaker infecting someone is pretty low as well. Didn't keep the media and most of the people on this thread to get upset, however.
Onco - I know that you're still (technically) pre-med, and, in some ways, I wonder how the transition into the world of medicine (from the world of business) will affect you. I'd never thought about it much before, but the schools of thought seem so...different as to be seemingly irreconcilable.
I'm not worried about it. I like to have fun talking about this stuff, but when it comes down to it, I just do my job like everyone else. I'm talking about stuff in theory. Obviously in the real world, companies dump toxic chemicals into the environment and expose workers to dangerous substances without disclosing anything. Just because something is against the law doesn't mean it doesn't happen with regularity. At the same time, there are companies and individuals that do respect proper practices, and that's mainly what I'm pointing to. There are physicians who get their patients hooked on painkillers to generate more revenue for themselves or perform unnecessary or low probability of success back surgeries and quite a few that are, well, generally incompetent, but I'm not going to go there either when I'm talking about what physicians should be doing or what our goals should be.
Most people like yourself know nothing else (you might be different) so you just think of medicine the way it is. I've got something to compare it to, so I enjoy doing that. I'm not suggesting that it will result in any improvements, but you never know. However, I realize I'm coming to medicine and not the other way around. I'll be on on new turf, do my best to learn the rules and play by them. It's neat to compare anyway.
The "right to know" doesn't supersede everything. If it doesn't affect your future agenda/decisions, you don't necessarily have the right to know.
* In microbio, I was taught by an ID physician that, if you don't have a treatment plan, don't run the test. Specifically - if you don't know for certain that you'll be able to treat a patient for TB (due to logistics, whatever), don't place the PPD. Since the result (either way) doesn't affect your plan of treatment, there's no need to place it.
* In biochem, I was taught by a pediatrician that neonatal screening is only done for diseases that have proven cures/treatment plans. There are many congenital diseases that they do not bother devising tests for, simply because they have no way of treating kids who are affected with those diseases. If you can't treat them, there's no useful point in knowing early on if they have that disease or not.
Yes, well, obviously we do have prophylactic and post-exposure procedures for HIV, HBV, HCV etc., so these aren't really relevant examples. We can do something about it.
Uh huh. To quote Dr. Cox from Scrubs: "I don't know if they taught you this in the land of fairies and puppy dog tails where you obviously, if not grew up, then at least spent most of your summers, but you're in the real world now! N'kay?"
The safest way to prevent discrimination is to make sure the information never makes it out there. How would you prevent an ambitious and competitive colleague from using this info to his benefit? How do you guarantee that the information will stay confidential?
I'm quite aware of discrimination. I'm also aware of the real world. I have no fairy tale notions. I know full well that people will do all kinds of bad things. At the same time, I would rather manage the risk of someone missing a promotion due to discrimination than the risk of someone dying prematurely due to a disease they contracted at a hospital. It's a question of priorities. I'm not suggesting that it's practical or feasible to improve the status quo. I'm just telling you my opinions, of course. I can put my opinions aside without missing a beat and do my job just like you will.
Also, there is plenty of information at a hospital that can be misused and abused. That's why there are rules and procedures and why you can be disciplined for not following them.
I know you have this habit of posting long abstracts from Pub Med. Please - stop. I'm not just saying this out of frustration, but there are real reasons:
Abstracts don't tell you anything useful. As you'll learn in med school, you have to read the whole article to truly understand what's going on.
Case in point: The first article from Med Lav. "Since 1972, 50 outbreaks have been reported in which 48 HBV infected HCWs (39 surgeons) transmitted the infection to approximately 500 persons." The abstract does NOT tell you what percentage of those outbreaks occurred after the mid 1990s, when Universal Precautions really became prevalent at hospitals in the US. It does NOT tell you how they ascertained that the physician was the actual source of the infection. It does NOT tell you what percentage of the infected physicians followed Universal Precautions and which did not.
This is why you're not supposed to use the abstract as evidence-based medicine. Your methods and discussions sections are much more important.
The same complaints hold true for the German article. What percentage of those cases occurred in the FIRST half of that 15 year period, and what percentage of those cases occured in the LATTER half of the period? What was the effect of the implementation of Universal Safety Precautions? I'll give you credit - at least that abstract had a link to the full article. Unfortunately, the thing's in German.
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Questioning the abstracts is a sign of desperation (as in not having much of a leg to stand on), in my opinion. Sure, we could go into the full-length articles and methods, but I'm not sure we would magically come to agreement there ... unlikely. I'll show you some more recent stuff below. I've read thousands of articles and abstracts and in most respected journals you get a pretty good idea of the article from the abstract. We're not just talking about one article here ... there are many. You have the text there; it's convenient for you. You really have nothing to complain about. Statements like this, "Abstracts don't tell you anything useful" are completely false as a general statement. Have you ever published a refereed journal article? It would be tough to get a misleading abstract past reviewers. I would say it's very rare. You might get away with a little promotion, but not much. Not suggesting there might not be one here or there, but I could quote several more articles that say the same thing and I hope you're not suggesting some kind of conspiracy theory.
Go ahead and quote your own abstracts & articles. I don't have a problem with it. If you have a different study, feel free to quote it as you did. Looking at your reference, I'm not really impressed at all. You didn't even quote a true paper. That's just a reply to another article.
Here are some articles:
Infect Control Hosp Epidemiol. 2002 Jun;23(6):306-12. Links
Comment in:
Infect Control Hosp Epidemiol. 2002 Jun;23(6):301-2.
Infect Control Hosp Epidemiol. 2002 Jun;23(6):303-5.
Infect Control Hosp Epidemiol. 2002 Nov;23(11):638.
Key points:
"DESIGN: A retrospective cohort study was conducted of 1,564 patients operated on by the surgeon. Patients were tested for serologic HBV markers. A case-control study was performed to identify risk factors. RESULTS: The surgeon tested positive for hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) with a high viral load. He was a known nonresponder after HBV vaccination and had apparently been infected for more than 10 years. Forty-nine patients (3.1%) were positive for HBV markers. Transmission of HBV from the surgeon was confirmed in 8 patients, probable in 2, and possible in 18. In the remaining 21 patients, the surgeon was not implicated. ... Although the risk of HBV infection during high-risk procedures was 7 times higher than that during low-risk procedures, at least 8 (28.6%) of the 28 patients were infected during low-risk procedures. CONCLUSIONS: Transmission of HBV from surgeons to patients at a low rate can remain unnoticed for a long period of time. Prevention requires a more stringent strategy for vaccination and testing of surgeons and optimization of infectious disease surveillance. Policies allowing HBV-infected surgeons to perform presumably low-risk procedures should be reconsidered.
N Engl J Med. 1997 Jan 16;336(3):178-84. Links
Transmission of hepatitis B to patients from four infected surgeons without hepatitis B e antigen. The Incident Investigation Teams and others.[No authors listed]
Public Health Laboratory Service Communicable Disease Surveillance Centre, London, United Kingdom.
BACKGROUND: Transmission of hepatitis B virus (HBV) to patients by infected surgeons who carry hepatitis B e antigen (HBeAg) has been documented repeatedly. In the United Kingdom HBeAg-positive surgeons are not permitted to perform certain procedures that carry a risk that patients might be exposed to the blood of a health care worker. There are no practice restrictions for carriers of hepatitis B surface antigen without detectable HBeAg, unless transmission has been demonstrated. METHODS: In four unconnected cases of acute hepatitis B, surgery was identified as a possible source, so we tested the surgical teams for serologic markers of HBV infection. In each case a surgeon was found to be infected with the virus. HBV DNA was amplified by a nested polymerase chain reaction from serum from the four infected surgeons and the four patients, and direct nucleotide sequencing of two regions of the HBV genome was performed. Alternative sources of infection were ruled out. Other patients on whom three of the surgeons had recently performed procedures were offered testing. RESULTS: All four surgeons were carriers of HBV, but none had detectable serum HBeAg. The nucleotide sequences of HBV DNA from the surgeons were indistinguishable from those from the corresponding patients. The screening of other exposed patients identified at least two other patients who had probably acquired hepatitis B infection from one of these surgeons. CONCLUSIONS: Surgeons who are carriers of HBV without detectable serum HBeAg can transmit HBV to patients during procedures.
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If the above didn't even disclose their HBV status, we wouldn't even be able to study the problem.
I agree that we could benefit from much better information and study of this area. For the time being, the concensus is to err on the side of caution and to have healthcare workers report their HIV/HBV/HCV infections because we can make them do it due to conditions of employment, school rules, etc. We don't have as much leverage on patients.
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And you're trusting that all HCWs will be properly objective enough to realize when they should turf this case off onto someone else? And how do you know, 100%, that postponing his treatment won't affect his health? And do you also see how, conceivably, this could come across as discriminatory treatment?
Look - your way isn't perfect either. It runs you into a whole other ethical gray zone, particularly if you let the patient's condition determine your treatment plans.
Not saying that we are going have HCW's turn into angels. At the same time, I think HCW's health and safety need to be respected, just like the patients. I agree that HCW's should disclose HIV/HBV/HCV and that patients should as well. Not saying it's going to happen; that's just my preference.
