From: Billi Goldberg <bigoldberg@igc.apc.org>
Subject: VA Summary 6/5/92
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Archive-Number: 5901
Organization: UCLA, Computer Science Department
Date: Fri, 14 Aug 92 16:43:38 PDT

This AIDS Information Newsletter was obtained from the HIV/AIDS Info
BBS (714) 248-2836.  It is the best source of AIDS Info available.
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                   AIDS INFORMATION NEWSLETTER
                   Michael Howe, MSLS, Editor
                     AIDS Information Center
                VA Medical Center, San Francisco
                     (415) 221-4810 ext 3305
                          June 5, 1992 
                      SPECIAL TOPIC ISSUE: BLOOD-BORNE DISEASE 
TRANSMISSION IN ORTHOPAEDIC SURGERY (Part I) 
PRELIMINARY ANALYSIS: HIV SEROSURVEY OF ORTHOPEDIC SURGEONS, 1991 
Reprinted from MMWR, 1991;40:309-12. 
     Although occupational transmission of human immunodeficiency virus 
(HIV) and other bloodborne pathogens to health-care workers from 
patients has been well documented, data on HIV seroprevalence in health-
care workers are limited. This report summarizes preliminary findings 
from a voluntary, anonymous HIV serosurvey among orthopedic surgeons, 
conducted by CDC in cooperation with the  American Academy of 
Orthopaedic Surgeons (AAOS), at the AAOS annual meeting in Anaheim, 
California, during March 6--12, 1991.
     All orthopedic surgeons registered for the meeting who were in 
postgraduate orthopedic surgical training programs, in practice, or 
retired from practice in the United States or Canada were invited to 
participate. Participants received pretest counseling, provided verbal 
informed consent, and completed an epidemiologic questionnaire to 
ascertain demographic and clinical practice characteristics, as well as 
the presence of nonoccupational risk  factors for HIV infection.* Names 
or other personal identifiers were not collected. Blood specimens were 
screened for HIV antibody by enzyme immunoassay (EIA); specimens 
repeatedly reactive by EIA were evaluated by Western blot within 48 
hours. HIV results and posttest counseling were provided anonymously to 
participants at the serosurvey site.
     To assess the representativeness of serosurvey participants,  
characteristics of this group were compared with those of all orthopedic 
surgeons who had completed a questionnaire survey (``Orthopaedic Surgeon 
Survey'') administered by AAOS in November 1990. This survey of 
demographic and clinical practice characteristics was mailed to the 
20,625 orthopedic surgeons known to AAOS to be in training, in practice, 
or retired from practice in the United States and Canada; responses were 
received from 10,411 (50%) (AAOS, unpublished data).
     Of 7121 orthopedists attending the AAOS annual meeting who were 
eligible for the serosurvey, 3420 (48%) participated. Based on the self-
administered questionnaire, most participants were male (97%) and aged 
30--54 years (75%). Compared with findings of the AAOS Orthopaedic 
Surgeon Survey, serosurvey participants were more likely to be in 
residency or fellowship training (18% vs. 14%); have trained or 
practiced in one or more geographic areas of high acquired 
immunodeficiency syndrome (AIDS) incidence** since 1977 (75% vs. 69%); 
have operated on one or more patients with known HIV infection (49% vs. 
43%); have had a patient's blood contact their skin in the previous 
month (87% vs. 83%); and have sustained a percutaneous injury (e.g., 
needlestick or cut) from a sharp object contaminated with a patient's 
blood in the previous month (39% vs. 34%). Fifty-one percent of 
serosurvey participants had been tested previously for HIV.
     Of the 3420 serosurvey participants, two were HIV seropositive 
(0.06%, upper limit 95% confidence interval (CI)=0.18%). In addition, 
eight specimens were reactive by EIA but indeterminate by Western blot; 
based on further testing at CDC with investigational peptide EIAs and 
recombinant DNA antigen assays for HIV antibody, seven of the eight 
specimens were classified as  HIV-antibody negative and one as 
indeterminate.
     Each of the two HIV-seropositive participants reported 
nonoccupational risk factors for HIV infection; therefore, among the 108 
surgeons reporting such risk factors, HIV seroprevalence was 1.9% (upper 
limit 95% CI=5.7%). In comparison, of the 3267 participants not 
reporting nonoccupational HIV risk factors, none were HIV positive 
(upper limit 95% CI=0.09%). Of the 45  participants who did not respond 
to the question on risk factors, none were HIV positive. The one surgeon 
whose serum tested indeterminate for HIV antibody did not report a 
nonoccupational risk.***
     Both of the HIV-seropositive participants were male and reported 
having performed surgery on patients with risk factors for HIV 
infection. One of the two surgeons reported performing surgery on 
patients with known HIV infection or AIDS. Although they had both 
sustained percutaneous injuries in the previous year, neither reported 
an injury from a sharp object contaminated with the blood of a patient 
known to have HIV infection or AIDS. The surgeon with an indeterminate 
result, a man who had retired from clinical practice, reported never 
having operated on a patient with known HIV infection or AIDS or on a 
patient with risk factors for HIV infection or AIDS.
     Although HIV testing of the serosurvey participants has been 
completed, testing for markers of hepatitis B and C virus infection is 
in progress. Additional analyses to assess representativeness of 
serosurvey participants and to characterize the nature and frequency of 
their occupational contact with blood are also under way. 
REPORTED BY:  American Academy of Orthopaedic Surgeons Serosurvey Study 
Committee. AIDS Activity, Hospital Infections Program and Laboratory 
Investigations Branch, Division of HIV/AIDS, Center for Infectious 
Diseases, CDC. 
 EDITORIAL NOTE:  The findings of this HIV serosurvey assist in 
evaluating the risk for occupationally acquired HIV infection in a 
subset of health-care workers with frequent occupational blood contact, 
including percutaneous injuries (4--6). Although these results may not 
be generalizable to all orthopedic surgeons, the findings do not 
indicate a high rate of previously undetected HIV infection among a 
large group of these surgeons, including those who trained or practiced 
in areas of high HIV/AIDS incidence.
     This serosurvey has at least three limitations. First, orthopedic 
surgeons who attended the AAOS annual meeting and participated in this 
study may not have been representative of all orthopedic surgeons in the 
United States. However, preliminary analysis suggests that the 
likelihood of occupational HIV exposure was at least as high for 
serosurvey participants as for the more than 10,000 surgeons responding 
to the AAOS Orthopaedic Surgeon Survey. Second, HIV seroprevalence may 
have been underestimated if orthopedic surgeons who knew they were HIV 
positive declined to participate. Third, the reliance on self-reporting 
may have affected the accuracy of the data on nonoccupational risk 
factors for HIV infection.
     The frequency of occupational blood contact and percutaneous injury 
reported by serosurvey participants and AAOS Orthopaedic Surgeon Survey 
respondents emphasizes the need for orthopedic surgeons and other 
health-care workers who are potentially exposed to blood and body fluids 
to continue to take appropriate precautions to prevent infection with 
HIV and other bloodborne pathogens. As previously recommended by CDC, 
such workers should receive hepatitis B vaccine, employ universal 
precautions, and receive appropriate counseling and follow-up after 
occupational exposure to HIV or hepatitis B virus (7--10). AAOS has 
developed additional recommendations for the prevention of HIV 
transmission during orthopedic surgery (11--13); copies are available 
from AAOS, 222 South Prospect Avenue, Park Ridge, IL 60068. 
 REFERENCES 1. CDC. HIV/AIDS surveillance report. Atlanta: US Department 
of Health and Human Services, Public Health Service, CDC, December 
1990:1--18. 2. CDC. Interpretation and use of the Western blot assay for 
serodiagnosis of human immunodeficiency virus type 1 infections. MMWR 
1989;38(no. S-7). 3. Dock NL, Kleinman SH, Rayfield MA, Schable CA, 
Williams AE, Dodd RY. Human immunodeficiency virus infection and 
indeterminate Western blot patterns. Arch Intern Med 1991;151:525--30. 
4. Panlilio AL, Foy DR, Edwards JR, et al. Blood contacts during 
surgical procedures. JAMA 1991;265:1533--7. 5. Tokars JI, Marcus R, 
Culver DH, Bell DM, Cooperative Study Group. Blood contacts during 
surgical procedures (Abstract). Program and abstracts of the 30th 
Interscience Conference on Antimicrobial Agents and Chemotherapy. 
Washington, DC: American Society for Microbiology, 1990:246. 6. 
Gerberding JL, Littell C, Tarkington A, Brown A, Schecter WP. Risk of 
exposure of surgical personnel to patients' blood during surgery at San 
Francisco General Hospital. N Engl J Med 1990;322:1788--93. 7. CDC. 
Recommendations for prevention of HIV transmission in health-care 
settings. MMWR 1987;36(no. 2S). 8. CDC. Update: universal precautions 
for prevention of transmission of human immunodeficiency virus, 
hepatitis B virus, and other bloodborne pathogens in health-care 
settings. MMWR 1988;37:377--82,387--8. 9. CDC. Public Health Service 
statement on management of occupational exposure to human 
immunodeficiency virus, including considerations regarding zidovudine 
postexposure use. MMWR 1990;39(no. RR-1). 10. ACIP. Protection against 
viral hepatitis: recommendations of the Immunization Practices Advisory 
Committee (ACIP). MMWR 1990;39(no. RR-2). 11. American Academy of 
Orthopaedic Surgeons Task Force on AIDS and Orthopaedic Surgery. 
Recommendations for the prevention of human immunodeficiency virus (HIV) 
transmission in the practice of  orthopaedic surgery. Park Ridge, 
Illinois: American Academy of Orthopaedic Surgeons, 1989. 12. American 
Academy of Orthopaedic Surgeons/National Association of Orthopaedic 
Nurses. Reducing the risk of blood-borne disease  transmission in 
orthopaedic surgery (Videotape and booklet). Park Ridge, Illinois: 
American Academy of Orthopaedic Surgeons, 1991. 13. American Academy of 
Orthopaedic Surgeons. Advisory statement: HIV-infected orthopaedic 
surgeons. Park Ridge, Illinois: American Academy of Orthopaedic 
Surgeons, 1991. 
 *Including receipt of blood transfusion during 1978--1985; receipt of 
clotting factor concentrate since 1977 for treatment of hemophilia or 
other coagulation disorder; male-male sexual contact at any time since 
1977; intravenous-drug use since 1977; birth in Haiti or in central or 
east Africa; or sexual contact since 1977 with someone in one of the 
above groups. Participants were not asked which specific risk factor(s) 
applied to them. 
 **One of 26 U.S. metropolitan areas reporting the highest cumulative 
number of AIDS cases (1) or in Africa or the Caribbean. 
 ***In general, among persons who are indeterminate for HIV antibody but 
without HIV risk factors, subsequent evaluation does not confirm HIV 
infection (2,3). 

                       ADVISORY STATEMENT
                HIV-INFECTED ORTHOPAEDIC SURGEONS 
            American Academy of Orthopaedic Surgeons 
     In this Advisory Statement, the Academy has made nine broad  
recommendations regarding the HIV-infected orthopaedic surgeon. These 
recommendations cover the issues of HIV testing, the appropriate scope 
of the HIV-infected surgeon's responsibilities, and the HIV-infected 
orthopaedic surgeon's obligation to his or her patients and healthcare 
facilities.  The Academy's recommendations are: 
Recommendation 1: The Academy believes that orthopaedic surgeons, like 
all other physicians, have a responsibility to know their own HIV status 
through periodic HIV testing.  Similarly, the Academy believes that, 
within the confines of the law, orthopaedic surgeons should have access 
to the HIV status of their status of their patients and, further, that 
physicians should promote the voluntary HIV testing of their patients. 
Recommendation 2: The Academy recommends that an HIV-infected 
orthopaedic surgeon should not perform invasive surgical procedures 
except in the specific, limited instances outlined in the full text of 
this Advisory Statement. 
Recommendation 3: The academy recommends that if the patient might be 
put at risk for HIV transmission because of invasive surgery by an HIV-
infected  orthopaedic surgeon, the HIV-infected physician has an 
obligation to inform the patient of his or her HIV status and of the 
relative risks involved prior to performing the invasive procedure. 
Recommendation 4: The Academy believes that the orthopaedic surgeon does 
not have an obligation to respond to patient inquiries regarding his or 
her HIV  status unless invasive procedures are to be performed. 
Recommendation 5: The Academy recommends that in an emergency situation 
where the patient's life or limb is threatened, and if no HIV-negative 
physician is available, then an HIV-infected physician should be able to 
perform invasive procedures provided that the patient or his/her family 
is informed of the physician's HIV status. 
Recommendation 6: The Academy recommends that an HIV-infected 
orthopaedic surgeon consider carefully the attributes of an exclusively 
office-based  practice where less risk of HIV transmission would exist. 
Recommendation 7: When and HIV-infected orthopaedic surgeon wishes to 
perform  invasive procedures and the patient is informed of the 
surgeon's HIV status and consents, the Academy concurs with the 
recommendations of the AMA and other national healthcare organizations 
regarding the reporting and handling of an  orthopaedic surgeon's HIV-
infected status within the healthcare institution. 
Recommendation 8: The Academy recommends, consistent with state law and 
the  healthcare institution's own guidelines, that if HIV-infected 
orthopaedic surgeons practice within parameters described in this 
Advisory Statement, they should be able to continue their career in 
medicine. 
Recommendation 9: The Academy recommends that once orthopaedic surgeons 
are  determined to be HIV-infected, they should consider availing 
themselves of support services and groups developed specifically for 
HIV-infected individuals in many communities. 

            REDUCING THE RISKS OF BLOOD-BORNE DISEASE
               TRANSMISSION IN ORTHOPAEDIC SURGERY 
Producer:  American Academy of Orthopaedic Surgeons, 222 South Prospect 
Ave., Park Ridge, IL 60068-4058.  Telephone:  (708) 823- 7186. 
Description:  30-minute videocassette and reference booklet, 1991 
Target Audience:  Orthopaedic Surgeons, Nursing OR Staff, Orthopaedic 
Surgery Assistants, Office and Clinic Staff 
Synopsis:  This two part video presents information on: the unique 
aspects of orthopaedic practice that risk exposure to blood- and body 
fluid-borne pathogens; preparation for orthopaedic surgery by using both 
universal precautions and specific techniques for unique operative and 
clinical environments; protection from exposure to blood, body fluids, 
and bone fragments in the operating room or clinic; handling instruments 
and supplies with reduced risk; observing proper disposal and packaging 
techniques for autoclaving material. The first part of the program 
demonstrates techniques that reduce the risk of bloodborne diseases 
transmission.  Subjects discussed include: the unusual exposure of 
orthopaedic surgery to blood and body fluids; necessary preparation 
before surgical cases; effective procedures to follow during surgery; 
appropriate equipment and supply handling; and material cleaning and 
disposal. The second part provides information on the situations and 
methodology that relate to the clinic. Subjects covered include: taking 
a meaningful patient history; safely performing common clinical 
procedures; proper cleaning and disposal of material; and steps to take 
if an exposure incident occurs.  Introductory remarks by Dr. Lorraine 
Day emphasize the risk of infection and the need for protection from 
blood-borne transmission. 
Related Materials:  A 48-page reference booklet offers supplemental 
information about blood-borne disease transmission and explores a 
variety of issues in greater detail than the video.  These include an 
overview of HIV and orthopaedic surgery, special techniques and 
precautions, elements of a patient history, surgical gowns, and selected 
additional resources. 
Evaluation:  The purpose of this video program is to educate those who 
work within the orthopaedic surgical specialty on the proper techniques 
for taking precautions in the operating-room and clinic to reduce 
transmission risk of blood-borne diseases.  The complete program is 
based on the premise that those in orthopaedic surgery are placed in a 
unique environment that increases risk by the complexity and technical 
nature of orthopaedic treatment, and the almost always present potential 
for contact with blood drainage. To compound this problem, the trauma 
patient adds another dimension because of the need for immediate and 
emergent care that often precludes a detailed history and serologic 
screening.  This program provides a number of precautionary procedures 
for orthopaedic practice in addition to the universal precautions 
suggested by Centers for Disease Control which are viewed as the minimum 
level  of barrier protection and infection control. 
Availability:  American Academy of Orthopaedic Surgeons, P.O. Box 
809287, Chicago, IL 60680-9287.  Telephone: (800) 626-6726. 
Reviewer Info:  Michael Howe, AIDS Information Center, Library Services 
(142D), VA Medical Center, 4150 Clement Street, San Francisco, CA 94121.  
Telephone: (415) 221-4810 ext 3305.  FTS 8- 700-470-3305. 
Review Date:  920520 
Notes:  Other documentation from the Academy includes an "Advisory 
Statement" for HIV-infected orthopaedic surgeons (reprinted in the 
reference booklet that accompanies the video) and a 25-page 
"Recommendations for the Prevention of Human Immunodeficiency Virus 
(HIV) Transmission in the Practice of Orthopaedic Surgery" developed by 
the AAOS Task Force on AIDS and Orthopaedic Surgeery. A copy of this 
video is located in the AIDS Information Center (WO 113 R321 1991). 

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