Current Trends Preliminary Analysis: HIV Serosurvey of Orthopedic Surgeons, 1991

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 prac tice, or retired from practice in the United States and Canada; responses were received from 10,411 (50%) (AAOS, unpublished data).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 Br, Div of HIV/AIDS, Center for Infectious Diseases, CDC.

Editorial Note

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 immuno deficiency 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).

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