Wednesday,
October 6, 1999
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A surgeon’s caution By Dr S.M. Bose AIDS has become the most notorious name among the ailments. A mere mention of the word scares everybody — and rightly so, because it is a fatal disease (with no hope of cure). A
physician’s overview Pancreatic disease: search for
relief Hope for ailing lungs |
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A surgeon’s
caution AIDS has become the most notorious name among the ailments. A mere mention of the word scares everybody — and rightly so, because it is a fatal disease (with no hope of cure). It has been estimated by the WHO that by the turn of this century there will be 40 million people in the world who will be affected by HIV infection while the number of full-blown aids cases will be about 12 million. It is apprehended that India will be one of the main countries to come under the grip of aids. It is estimated that 10 per cent of the total number of the cases of aids in the whole world will be in India. The human immunodeficiency virus (HIV), after its entry into the human body, causes a progressive state of immunodeficiency. The end stage of this deficiency is known as Acquired Immunodeficiency Syndrome (aids). It is characterised by a profound suppression of cellular immunity, resulting in opportunistic infections by organisms of low pathogenicity. The knowledge of aids in relation to surgery is very important as not only there is a high risk of transfer of the disease from the patient to medical and paramedical staff; other patients and their attendants are also at a very high risk of getting the infection in case adequate precautions are not taken. In addition, while undertaking surgery in an HIV-positive patient, one has to undertake some special measures to adjust to the immunodeficient status of the patient. It should be remembered that a patient of aids cannot be denied any treatment that is indicated. HIV infection is no contraindication for surgery. Surgery means spillage of blood and, therefore, contact with HIV-infected blood and with some tissue fluids like saliva, semen, tears, urine and cervical secretions may inoculate a person. Human immunovirus has been isolated from each of these body fluids. It is necessary that one should not come in direct contact with any of the tissue fluids of an HIV patient. Every member of the surgical team should avoid this in the operation theatre, the OPDs, wards, laboratories and other places of contact. The prevalence of HIV in the surgical patient population is one in 10,000. The rate of HIV transmissibility after accidental occupational exposure ranges from 0.2 per cent to 0.5 per cent. The possibility of transmission from any patient to a surgeon is one in 1.3 million. The routine screening of all the surgical patients is, therefore, not a viable proposition. It is heartening to note that no case of sero-conversion (from an Aids patient to a member of the surgical team) has been recorded so far in our country although such cases have come on record from other parts of the world. Precautions in OPDs: In addition to all the known precautionary measures that are applicable for handling any infectious disease, one should be very careful in the OPDs, where, because of the great rush, the medical staff may become lax in undertaking precautionary measures. This is more important because in the OPDs the level of suspicion may be also very low and this may further complicate the situation. It is recommended that precautionary measures should get incorporated and should become a habit with us. Then only we will be able to ward off the dreaded infection. Specimens and request forms are clearly marked with the words "risk of infection". The specimens are placed in double-sealed plastic bags. The precautions, at the laboratory level, should be taken mandatorily. One should be very particular in wearing gloves and protecting eyes while undertaking oral or rectal examinations and also while performing any endoscopic examination. It is always advisable to use disposable instruments while tackling either patients of aids or patients at a high risk of getting HIV infection (homosexual males, IV drug-abusers, haemophiliacs, prostitutes, sexual partners of these, etc.) It is advisable to use video-endoscope while performing endoscopy so as to avoid spillage and shower of secretions on the face. In the wards: The precautions are the same as in the OPDs. In addition, one has to be doubly careful while doing dressing and minor surgical procedures like venepuncture and venesection, catheterisation, spinal puncture and the tapping of any visceral cavity. The patient has to be kept isolated with all the known precautions that are taken for any infectious case. In operation theatres: In addition to well-established precautionary measures undertaken while performing surgery on any infectious case, additional preventive steps are recommended while undertaking surgery on patients of aids. It is ideal to have a separate operation theatre designated for surgery on patients of aids only, but it may not be feasible. One of the OTs should be used for this. All the unnecessary equipment and items should be removed from the OT, the number of persons allowed entry should be limited, anyone with abrasions or lacerations on hands and feet should not be allowed to participate in the operation and the conversation inside the OT should be minimised. All the staff should wear overshoes, water resistant aprons beneath the gown, and proper eye shields. Double-gloves are mandatory and after a period of 90 minutes the gloves should be changed. It is recommended to have all these items (particularly linen, glove, shoe cover, draping material etc) to be disposable and these should be properly disposed of after use. But in case it is not feasible to dispose of any item, it should be handled carefully as per the standard recommendations. Sharp injuries are the most significant risk factor for sero-conversion. Surgeons and their assistants account for 65 per cent of all sharp injuries. Other factors affecting sero-conversion are: the amount of the patient's blood transferred, the state of disease progression in the patient and the use of post-exposure chemoprophylaxis. Several studies suggest that the frequency of percutaneous injury is at least one in 40 cases, for some as high as one in 20 cases; i.e., if a surgeon operates upon 40 HIV cases, there is the probability that he will get injured at least once. That may inoculate him with HIV. Based on this estimate, it is crucial not only to take precautionary measures but also to limit the surgeon's exposure to HIV-infected patients. Surgical techniques should be modified to minimise the risk of sharp injury. No touch technique should be used so that sharp instruments like needles, scalpels, or scissors are not handed over directly by the scrub nurse to the surgeon (and vice versa) but the instrument is placed in a kidney tray and is picked up by the surgeon. Diathermy, staples and clips are preferred in place of suturing techniques. Some relative risk factors in the surgery for HIV inoculation have been identified and they are: deep puncture (16 times more risky than superficial scratch), puncture with large bore needles or hollow instruments, puncture directly into the blood vessels, the amount of the patients' blood transferred and the rate of disease progression in the source patient. The patient, after the operation, is kept in the operation theatre for full recovery from anaesthesia and is subsequently directly transferred to his isolation ward. He is not taken either to the post-operative or intensive-care unit. It has been well accepted that the observance of the universal precautions is the answer to the question: "How to contain the HIV threat to the surgeons and the members of their teams?" The universal precautions are the same as that for hepatitis and consist mostly of the measures that are taken for preventing the spread of infection in the hospital environment. Inactivation of the aids virus: The Human Immunodeficiency Virus can be inactivated by any of the following measures: Boiling kills the virus very quickly. Ethanol 70 per cent (700 gm per litre) Glutaraldeyde 2 per cent (commercial name Cidex) Formaldehyde 5 per cent (50 gm per litre) Chlorine - sodium hypochloride, 10 per cent solution Lysol 0.5 per cent solution. Treatment: Treatment with AZT should be given to all persons who have been accidentally exposed to an HIV patient but it should be also clearly understood that there is no prophylactic role of AZT. It has also been stated that drugs can prolong survival for certain groups of patients but HIV infection remains a fatal disease. Dr Bose
is the Professor of Surgery at the PGI, Chandigarh. |
A
physician’s overview In India the HIV/aids epidemic is a decade old. In this short period it has emerged as one of the most serious public health problems. According to one publication which is aptly titled "aids Hits Indian Population with Monsoon Force" it is estimated that five million Indians are infected with HIV, a number greater than found in any country in absolute terms. The epidemic is fairly young with most people becoming infected in the past five years. The epidemic has hit the southern part of India with almost half of India's HIV cases located in and around Mumbai. The extent of the infection may be an underestimation as surveys have not been conducted all over the country. There is a wide gap between the reported and estimated figures as the officially reported cases of HIV infection and full-blown aids cases number a few thousand only. The disease now affects all parts of the country and in recent times there is a spread from urban to rural areas and from people practising high-risk behaviour to the general population. More and more cases of women getting infected are coming to light and at present one in every four cases reported is a woman. About 75 per cent of infections occur from the sexual route, about 8 per cent through blood transfusion and another 8 per cent through injectable drug abuse. Almost 90 per cent of all infections occur in the economically productive age group of 15-59 years. The major factors facilitating the spread of infection are migration and mobility of the population in search of employment, low levels of literacy and low rates of the use of "protection" in the form of condoms, etc. Adding to the HIV epidemic in India is the problem of tuberculosis. Nearly 60 per cent of HIV/AIDS cases are reported to be with tuberculosis as the opportunistic infection. Lack of compliance with treatment regimens is a big problem and has often resulted in the development of resistance to commonly used drugs. Further, some drugs that are used in patients with tuberculosis who have no HIV infection are likely to produce more complications in individuals in whom both infections coexist. The increased prevalence of tuberculosis in the HIV-infected population is adding a substantial number of patients to the already large reservoir of patients that already existed prior to the arrival of the HIV bug. So immense is the problem in some African countries that it is expected to lead to some major reverses in the already fragile economies. People with HIV/AIDS have a variety of health-care and social support needs during the course of their illness. A major problem is the persisting stigmatisation of and the discrimination against HIV-infected individuals. Even in the medical community there still is a mindset which suggests that nothing can be done, that care of these patients is a bottomless pit and that clinical services are not essential as the law of diminishing returns operates. This is compounded by the misgiving that HIV is a contagious disease and patients need to be kept in separate wards in some form of isolation. In fact, patients can be managed wherever a minimum level of hygiene can be ensured. The ultimate irony of the situation is that so long as the fact that an individual is HIV-positive is not known, it is fine with the treating team. Once the diagnosis is made, often, "reasons" appear as to why that particular individual cannot be treated any further! If one is aware that a certain person has been infected, adequate precautions can be taken. If there is any danger, it is from those infected cases of which the health-care providers are not aware. The management of opportunistic infection, including tuberculosis, can be an expensive proposition. In our country there is virtually no mention of treating the virus itself. Manuals only talk about the treatment of opportunistic infections. In fact, if the incidence of opportunistic infections has to decline, one has to develop drugs that are potent inhibitors of viral multiplication. Unfortunately, for treatment according to the current recommendations, the cost of the therapy is about Rs 25,000 per month, something that only a minuscule of the infected population can afford. So, there is an urgent need to develop drugs that target the virus and are made available at a price that the infected patients can afford. An effective vaccine can be a useful addition. More potential candidates are being tried than ever before. However, at a realistic level, no one expects a major breakthrough in the near future. In addition, there is a need for targeted intervention so as to reduce the rate of transmission among the high-risk behaviour practising population by bringing a change in behaviour through health promotion and education and provision of appropriate facilities and services. This is easier said than done. Changing people's behaviour is not easy and this is more so when it relates to issues that are personal and sensitive in nature. How many smokers know that smoking is injurious to health and how many leave it because of that knowledge? Some, of course, may have left it several times! Ignorance and indifference are a deadly combination. Literally in this context, ignorance is not bliss. Studies carried out in target groups have shown that most individuals do not have accurate information regarding HIV infection. Many people mistakenly believe that the transmission of HIV is limited only to certain groups like sex workers, intravenous drug-users and homosexuals. In areas where there has been a concerted effort by social organisations to educate people there is evidence of changed perception and behaviour. The importance of the work that social and other non-government organisations can perform cannot be overemphasised. Soon after the first few cases of this infection were reported, the Government launched a National AIDS Control Programme in 1987. There is a programme for all major diseases — like tuberculosis and malaria. The aim of this programme was to establish a comprehensive, multisectoral scheme to prevent and control HIV infection in India which would prevent HIV transmission, reduce morbidity and mortality associated with HIV infection and minimise the socio-economic impact resulting from HIV infection. This is the one big government agency that has been entrusted with the responsibility of controlling HIV infection. The magnitude of the problem has become so great that unless something drastic is immediately done, Emergency Medical Services in our country would look like a railway station where a number of trains have arrived simultaneously, each carrying loads of HIV-positive people. If there is a Y2K problem, it is HIV infection. The wake-up call came long ago; now the alarm bells are ringing. It is time we listened to them. The
writer is a clinical immunologist and an Assistant
Professor in the Department of Internal Medicine at the
PGI, Chandigarh. |
Pancreatic disease: search for relief The prevalence of pancreatic disease is increasing worldwide both in developed and developing countries. The objective of the three-day (October 8 to October 11) conference being organised by the Department of Surgery, PGI, Chandigarh, is to review the advancement in its diagnosis and management. The past several years have witnessed new developments not only in our understanding of the complex disorders but also new therapeutic modalities. More understanding of the local and systemic inflammatory response to the primary pancreatic insult offers potential therapeutic interventions that physicians will apply in the next millennium. Alcohol consumption is considered one of the important causes. There is no safe level below which pancreatic disease does not occur. As alcoholism among the young is increasing in India, an increased incidence of pancreatic disease is to be expected. Many patients are emaciated due to malabsorption and poor nutrition and have diabetes mellitus. Malnutrition seems to have a definite role in the aetiology of pancreatitis. Tropical pancreatitis is seen among the deprived sections of the people who eat a protein-and-calorie-deficient diet and exhibit signs of malnutrition. In South India, this very population eats a diet derived from the poor man's tuber — cassava, which contains almost pure starch with very low protein. The pancreas is very vulnerable to protein deficiency. The possibility of damage to pancreas inflicted by protein deficiency during infancy or early childhood deserves consideration. The cancer of the pancreas is a devastating illness and the prospects for cure are minimal. The lack of curative treatment emphasises the importance of understanding the aetiology of the disease so that preventive strategies can be developed. Pancreatic cancer is tobacco-related and almost 24% of the pancreatic cancer is directly attributable to smoking. Factors identified as increasing pancreatic cancer risks are high energy intake, cholesterol and meat. Vegetables and fruits may decrease the risk. Public health programmes to discourage smoking are vital for preventing this cancer. There has been an explosive accumulation of molecular genetic information concerning pancreatic disease in the past several years. Tumour-suppresser genes have been shown to be associated with cancer. Genes are also being implicated in pancreatitis. Pain is the most troublesome aspect of pancreatic disease and relief of pain is difficult. Patients often require large and frequent doses of pain killers leading to a high risk of drug dependence. A large number of surgical procedures have been employed. However, pain relief is a multidisciplinary approach. Clinicians have an important part to play in research which will not only benefit patients but also lead to accurate disease identification. The times are exciting for pancreatologists. An ICMR-sponsored task force meeting will be held to identify future multicentre research and for filling in the significant information gaps soon. Nearly
400 delegates from India and abroad are scheduled to
participate in the conference. The international faculty
will comprise eminent scientists from the USA, the UK,
Hong Kong, Japan, Hungary, New Zealand, Switzerland and
South Africa. A number of memorial lectures have also
been planned. - Dr P.N. Chhuttani, Dr H.S. Sachdeva and
Prof S.S. Anand memorial lectures are three of them.
— RNK & JDW |
Hope for ailing lungs The findings have led the Public Health Service/ Infectious Disease Society of America (IDSA) to change the recommendation of routine evaluation of anergy in HIV-infected persons, and to discontinue recommending INH prophylaxis in cases of anergic individuals. They do, however, continue recommending PPD skin testing annually in HIV-positive persons irrespective of their CD4 count. The lesson that we Indians can draw from these observations is that we just have to watch the HIV positive cases extremely closely and treat TB very, very early, rather than relying on a loosely administered prophylaxis programme using INH which would only lull us into a fool’s paradise. Two drugs, two months A study that could have global implications on the prevention of tuberculosis (TB) was presented at the 5th Conference on Retroviruses and Opportunistic Illnesses held in Chicago last year. Conducted in the United States, Brazil, Haiti and Mexico, the trial compared a short two-month regimen of rifampin (450-600 mg/day) plus pyrazinamide (20 mg /kg daily) to a one-year regimen of daily isoniazed (300 mg / day ). Twelve months of isoniazed (INH) is the present standard of care in the prevention of tuberculosis in HIV-positive individuals with a history of a positive TB skin test reaction, which marks latent as well as active disease. Once infected with the TB bacillus, HIV-positive persons are ten times more likely to develop active TB than HIV-negative persons. It has also been shown that TB promotes HIV replication and increases viral load and possibly contributes towards HIV disease progression and mortality. Thus, any intervention to prevent TB reactivation through easier regimens that promote improved compliance or lend themselves to directly observed therapy is worth investigating. Since TB is one of the most prevalent infections in the world, especially in developing countries, the importance of having a shorter preventive regimen could have far-reaching implications in terms of both TB and HIV morbidity and mortality. The prevention study enrolled 1,583 participants, who were randomized to one of the two treatment regimens between September 1991 and May 1996 and followed through to the end of October 1997. The average entry CD4 count was 436 cells, and 7% of study subjects had a history of AIDS. Significantly more participants in the shorter regimen (80% versus 63%) completed treatment, yet more participants in the two-drug arm had to discontinue due to side effects (9.5% versus 6.1%). Confirmed tuberculosis occurred in 19 of the 791 participants in the rifampin\pyrazinamide arm as compared to 24 of 792 participants enrolled in the INH arm, a nonsignificant difference. The rates of developing drug-resistant TB were very low and not significantly different for either group, as were the proportions of participants who developed pulmonary, extrapulmonary of combined disease. The death rates also were similar: 5.7% in the rifampin\pyrazinamide group as compared to 6.6% in the INH group. The overall incidence of reportable adverse effects was also similar in both arms: 12.3% versus 10.5%, favouring the INH group slightly. There were 2 cases of drug-related hepatitis in each group. Four participants in the INH group developed peripheral neuropathy as compared to one participant in the two-drug group. Dr Fred Gordin, M.D., the Protocol Chair and leader of the international team, concluded that the study supported the use of the short-course rifampin\pyrazinamide over yearlong INH, as the rates of tuberculosis reactivation, survival and overall side effects were similar. Once all the data are analysed and confirmed, it is expected that this study will lead to a change in the recommendation for the prevention of TB in HIV-positive persons. But injection drug users on methadone maintenance may not tolerate this regimen well. This is because rifampin induces the cytochrome P450 hepatic enzymes, leading to enhanced methadone metabolism and possibly to methadone withdrawal symptoms. Similarly, the short-course regimen is not likely to be useful for those on protease inhibitors, which also have drug-drug interactions with rifampin. In most cases, rifampin is contraindicated with protease inhibitors, and rifabutin is recommended as an alternate for the treatment of active TB. However, the relative effectiveness of rifabutin in preventing TB has not yet been determined. If HIV-TB continues unchecked in India, we too will have to look at such regimens with more than academic interest. Unfortunately, that day does not appear far off. Projection:
Kamaleshwar Sinha |
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