Potential for reported needlestick injury prevention among healthcare workers through safety device usage and improvement of guideline adherence: expert panel assessment.

A prospective survey was conducted over six months in order to estimate the proportion of reported occupational needlestick injuries sustained by National Health Service (NHS) Scotland staff that could have been prevented through either safety device introduction, improved guideline adherence, guideline revision or a combination of these. This survey involved the administration of a standard proforma to healthcare workers followed by an expert panel assessment. All acute and primary care NHS Scotland trusts, the Scottish Ambulance Service and the Scottish National Blood Transfusion Service were included. Proforma and expert panel assessment data were available for 64% of injuries (952/1497) reported by healthcare staff. These injuries were all percutaneous. The expert panel concluded that: 56% of all injuries and 80% of venepuncture/injection administration injuries would probably/definitely have been prevented through safety device usage, 52% of all injuries and 56% of venepuncture/injection administration injuries would probably/definitely have been prevented through guideline adherence and 72% of all injuries and 88% of venepuncture/injection administration injuries would probably/definitely have been prevented through either intervention. Multi-factorial analysis indicated that injuries sustained through venepuncture/injection administration were significantly more likely to be prevented through safety device usage [adjusted odds ratio (OR) 5.09, 95% confidence intervals (CI) 3.11-8.31 and adjusted OR 2.70, 95% CI 1.64-4.45, respectively], and significantly less likely to be prevented through guideline adherence (adjusted OR 0.26, 95% CI 0.11-0.60 and adjusted OR 0.31, 95% CI 0.12-0.78, respectively). Injuries sustained after completing procedures were significantly more likely to be prevented through safety device usage and guideline adherence. The study's findings support the need for improvements to staff's adherence to needlestick injury guidelines and appropriate implementation of safety devices for venepuncture and injection administration.

Evaluation of a new hepatitis B triple-antigen vaccine in inadequate responders to current vaccines.

In this double-blind, randomized, controlled study, healthcare professionals with a history of inadequate response to currently available single-antigen hepatitis B vaccines confirmed by measuring hepatitis B surface antibody titer before entry to the study were revaccinated with a 20-microg dose either of a novel triple-antigen (S, pre-S1, and pre-S2) recombinant vaccine or of a present single-antigen (S only) vaccine. Hepatitis B surface antibody titers were measured 8 weeks' post revaccination. A total of 925 individuals were randomized and vaccinated, of whom 915 (98.9%) completed the study and were included in the efficacy analysis. A single dose of the new triple-antigen hepatitis B vaccine (Hepacare) produced a successful response in over three quarters of these subjects who had not mounted an adequate response to current vaccines. The antibody response was statistically significantly superior (P =.002) to that after a single dose of current vaccines. An evaluation of the overall response showed that only the triple-antigen vaccine was able to raise the average antibody response (geometric mean titer [GMT]) to over 100 IU/L. The superior effect of the new vaccine was most pronounced in subjects who were previously complete nonresponders to currently available hepatitis B vaccines. Both vaccines were well tolerated and had similar safety profiles. This study demonstrated that in healthcare workers who had responded inadequately to at least a full course of immunization (median, 5 doses), a single 20-microg dose of a new triple-antigen vaccine induced protective antibody level in more vaccinees (P =.002) and increased the average antibody titer (GMT) in those protected successfully to a greater degree (P <.001) than a further attempt with a current vaccine (Engerix-B).

A study of hepatitis C prevalence in healthcare workers in the West of Scotland.

BACKGROUND AND AIMS: Whether healthcare workers have an increased prevalence of hepatitis C virus infection as a result of exposure to patient's blood and body fluids is controversial. This study assesses the prevalence of hepatitis C virus infection in healthcare workers, and its relation to the performance of exposure prone procedures and duration of occupational exposure, allowing an estimate to be made of the incidence of occupationally acquired hepatitis C infection among medical staff. METHODS: In this anonymous retrospective cohort study, we estimated the prevalence of hepatitis C infection in 10 654 healthcare workers. ELISA-3 testing was performed on pools of five sera collected during immunisation against hepatitis B. Healthcare workers were arranged into five occupational groups, according to the degree of patient exposure, and three age bands (<30 years, 30-39 years, >40 years). RESULTS: Prevalence of antibodies to hepatitis C was 0.28% (30/10 654), comparable in all occupational groups (p=0.34) and unrelated to duration of potential exposure. Assuming that all detected infections had been occupationally acquired, the maximum estimated risk of hepatitis C infection in exposure prone medical staff was low: 1.4% for surgeons and 1.0% for physicians over a 35 year professional career. CONCLUSIONS: Hepatitis C infection is infrequent in healthcare workers in Glasgow. Those conducting exposure prone procedures do not seem to be at higher risk than other healthcare staff.

Do occupational physicians agree about ill-health retiral? A study of simulated retirement assessments.

A questionnaire survey on simulated ill-health retirement decisions was performed at a scientific conference for local authority medical advisers. Respondents were asked to make decisions based on ten case scenarios drawn from real life. The overall agreement amongst 35 physicians was low, with a kappa statistic of 0.241. There were wide variations amongst respondents, with two physicians accepting all ten cases for retirement while another accepted only one. The survey suggests that there is great potential for inconsistency and inequity in such decisions. An improvement in agreement between physicians might be achieved by training, consensus guidelines and audit. This issue should be addressed by occupational physicians and trustees of superannuation schemes.

Influence of smoking on immunological responses to hepatitis B vaccine.

When 115 health-care workers participated in a study that monitored their serological responses to hepatitis B vaccine at regular intervals, it was found that smoking significantly affected their antibody titre responses adversely. The study group was randomly allocated into two comparable groups that received hepatitis B vaccine either in a rapid schedule (vaccination at 0, 1, 2 and 12 months) or a standard schedule-most commonly used worldwide-(vaccination at 0, 1, and 6 months). A significantly higher proportion of smokers, in both schedules, failed to seroconvert and to achieve higher antibody levels at month 3 (p = 0.01) and at month 13 (p = 0.0003). At month 7 a similar pattern was noted in smokers following the standard vaccination schedule (p < or = 0.05), but not in those following the rapid schedule.

An audit of occupational medicine consultation records.

There is a need to develop and test methods of audit of the consultation process in occupational medicine and to draw conclusions from the findings. An external audit was carried out on 313 randomly selected consultation records from the occupational health services of three health boards over a 26-month period. Additionally, nine months after the date of the first externally audited sample, a prospective internal audit was commenced within one board. In 58 of the consultations selected (19 per cent), audit was not possible mainly because records could not be found. In an appreciable proportion of the rest, there were shortcomings in the referral record or in the consultation record. The consultation records of 'career' occupational physicians were better than those of 'non-career' physicians, especially in recording specific diagnoses (91 per cent vs. 67 per cent; P < 0.0001) and in conclusions regarding occupational implications (86 per cent vs. 74 per cent; P < 0.0001). Multivariate regressions showed a highly significant improvement associated with prospective internal audit in one item, namely the record of occupational implications. However, the magnitude of this difference before and after audit was smaller than the independent difference arising from the career status of the physicians. The value of medical audit in improving quality of care and education in occupational medicine is discussed.

Occupational physicians and their work: prospects for audit.

An anonymous postal questionnaire was sent to 200 occupational physicians in the UK to determine their activities, the nature of the organizations within which they work and their attitudes and practices with respect to audit. One hundred and sixty-six physicians responded to the questionnaire, of whom 119 (72 per cent) were currently practising occupational medicine. Fifty-seven (48 per cent) of these 119 were engaged in some form of audit but only 21 (18 per cent) were engaged in an audit of structure, process and outcome. Assessment of continuing fitness for work or sickness absence ranked first overall with respect to the proportion of the physician's time engaged. The study revealed a wide diversity in the organization of the practice of occupational medicine, in the qualifications of occupational physicians and in their participation in audit. Needs for the development and wider implementation of methods of audit in occupational medicine have been identified by the study.

Experience with hepatitis B vaccination in nurses in a hospital for the mentally handicapped.

The extent of HBV infection in the staff of a large hospital for the mentally handicapped was investigated. Nurses with direct patient contact were identified as a particular risk group and hepatitis B vaccination was offered to them. Of the 500 who received a full course of vaccination 96% had detectable antibodies 9 months after starting vaccination. High titres (over 1000 IU/l) were found in 59.4%. Females responded better than males and the response was age-dependent. In only 2 of 20 non-responders did lasting immunity develop with a fourth dose of vaccine. Antibody titre decreased rapidly in all vaccinees followed up. In vaccinees with an initial titre above 100 IU/l the decrease in titre could be reversed by a booster dose. Those with a titre below 100 IU/l had a variable response to the booster dose and lasting immunity developed in only a few. A recall system was started that predicts when a booster dose will be required to maintain a protective level of antibody. Servicing such a vaccination programme is not easy.

Effect of smoking and dietary saturated fats on platelet functions in Scottish farmers.

Coagulation and platelet aggregation to thrombin and adrenaline, before and 10 min after smoking one high nicotine cigarette, were studied in 40 healthy male farmers (40 to 45 years) from the South-West and North-East of Scotland. These tests were conducted in association with detailed dietary studies. In the West group the intake of dairy fats, saturated fats and P/S ratio as well as most of the platelet function tests estimated were significantly higher than in the East group. Serum cholesterol (total and HDL) was similar in the two regions, while triglycerides were lower in the West. Smoking one cigarette considerably enhanced the platelet functions in both areas but the increases were more marked in the West group. The increase in the response of platelets to smoking was additive to that apparently induced by the intake of saturated fat in such a way the response of platelets to thrombin and epinephrine after smoking one cigarette in the West was approximately four times this obtained before smoking (or in a non-smoker) in the East. These additive effects of cigarette and saturated fat might be relevant to the reported higher incidence of coronary heart disease in the West of Scotland.

Platelet functions in relation to diet and serum lipids in British farmers.

Coagulation and platelet aggregation induced by thrombin, ADP, adrenaline, and collagen were studied in three contrasted groups, each of 20 to 22 middle-aged male farmers. Serum lipids were similar in the three groups. In the west of Scotland group, however, platelet reactivity was significantly greater than in the east of Scotland. This was associated with a dietary intake, evaluated by three different techniques, higher in saturated fat but also lower in polyunsaturated fat and alcohol. Platelet function in the southern England group also correlated with dietary fats and in addition inversely with calcium intake. On an individual basis in the 63 farmers, all the platelet function tests were significantly correlated with the intake of saturated fat regulated by that of calcium and alcohol. The dietary effects on platelets appear to be mediated by the fatty acid composition of plasma lipids and of platelet phospholipids. In that fraction, the fatty acids 20:3 omega 9, 22:3 omega 9 and 20:4 were the most closely related to the platelet function tests. the trienoic acid 20:3 omega 9, identified with essential fatty acid deficiency, was also correlated with the intake of saturated fat and calcium. In this study, platelet functions were more dependent upon the dietary factors associated with coronary heart disease such as saturated fats, calcium, and alcohol than upon serum lipids.