www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
The
seroprevalence
of
hepatitis
B,
hepatitis
C,
and
human
immunodeficiency
virus
in
patients
undergoing
septoplasty
夽
Ozlem
Onerci
Celebi
∗,
Ela
Araz
Server,
Bahtiyar
Hamit,
Özgür
Yi˘
git
IstanbulEducationandResearchHospital,DepartmentofOtolaryngology,Istanbul,Turkey
Received28August2016;accepted26October2016
KEYWORDS Septoplasty; HBV; HCV; HIV; Seroprevalance Abstract
Introduction:Worldwide, hepatitis B virus,hepatitis Cvirus, andhuman immunodeficiency virusaremajorhealthproblems.Healthcareworkersareatriskoftransmittingblood---borne viruses,andsurgeonshaveahigherriskofexposuretobloodandhigherratesofpercutaneous injurythanotherhealthcareworkers.Septoplastyisamongthe3mostcommonlyperformed otolaryngologicalsurgeriesworldwide.
Objective: TodeterminetheseroprevalenceofHepatitisBsurfaceantigen,HepatitisCvirus antibody,andHumanImmunodeficiencyVirusantibodyinpatientsundergoingseptoplastywith and without turbinate surgery undergeneral anesthesia,and to determine if preoperative testingshouldbeperformedinsuchpatients.
Methods:Thisretrospectivecross-sectionalstudyincluded3731patientsthatunderwent septo-plastywithandwithoutturbinatesurgerybetweenJanuary2005andJuly2015.HBsAg,anti-HCV, andanti-HIVseropositivityinthepatientswasevaluatedretrospectively.
Results:Meanageofthepatientswas36years(range:11---81years).Inall,117(3.6%)patients werepositiveforHBsAg,12(0.3%)werepositiveforanti-HCV,and7(0.2%)werepositivefor anti-HIV.
Conclusions: Educationofhealthcareworkerscombinedwithroutinepreoperativeserological testinginpatientsundergoingseptoplastyundergeneralandlocalanesthesiaareneededto increase awarenessof hepatitisB and C, andHIV infectionamong healthcare workers and patientsinordertodecreasethetransmissionrate.
© 2016 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).
夽 Pleasecitethisarticleas:OnerciCelebiO,ArazServerE,HamitB,Yi˘gitÖ.TheseroprevalenceofhepatitisB,hepatitisC,andhuman immunodeficiencyvirusinpatientsundergoingseptoplasty.BrazJOtorhinolaryngol.2016.http://dx.doi.org/10.1016/j.bjorl.2016.10.008
∗Correspondingauthor.
E-mail:oonerci@yahoo.com(O.OnerciCelebi).
http://dx.doi.org/10.1016/j.bjorl.2016.10.008
1808-8694/©2016Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE Septoplastia; HBV; HCV; HIV; Soroprevalência
SoroprevalênciadehepatiteB,hepatiteCevírusdaimunodeficiênciahumanaem pacientessubmetidosàseptoplastia
Resumo
Introduc¸ão:Nomundotodo,ovírusdahepatiteB(VHB),ovírusdahepatiteC(VHC)eovírus daimunodeficiênciahumana(HIV)sãoproblemas desaúdeimportantes. Osprofissionais de saúdecorremoriscodetransmitirvírustransmitidospelosangue,eoscirurgiõestêmummaior riscodeexposic¸ãoaosangueetaxasmaiselevadas delesõespercutâneasdoqueosoutros profissionaisdesaúde. Aseptoplastiaestáentreastrêscirurgiasotorrinolaringológicasmais comumenterealizadasemtodoomundo.
Objetivo:DeterminarasoroprevalênciadeanticorposHBsAg,anti-HCVeanti-HIVempacientes submetidosaseptoplastiacomesemcirurgiadeconchanasalsobanestesiageraledeterminar sedeveserrealizadotestepré-operatórionessespacientes.
Método: Esteestudotransversal retrospectivoincluiu3731pacientesqueforamsubmetidos àseptoplastiacomesemcirurgiadeconchanasalentrejaneirode2005ejulhode2015. A soropositividadeparaHBsAg,anti-HCVeanti-HIVnospacientesfoiavaliadaretrospectivamente. Resultados: Aidademédiadospacientesfoide36anos(intervalo:11-81anos).Aotodo,117 (3,6%)pacientesforampositivosparaHBsAg,12(0,3%)forampositivosparaanti-HCVe7(0,2%) positivosparaanti-HIV.
Conclusões:Aeducac¸ãodeprofissionaisdesaúdecombinadacomtestessorológicosrotineiros pré-operatórios em pacientes submetidos a septoplastia sob anestesia geral e local são necessáriospara aumentaraconscientizac¸ãosobre ahepatite Be Ce ainfecc¸ão peloHIV entreprofissionaisdesaúdeepacientesparadiminuirataxadetransmissão.
© 2016 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Worldwide,hepatitisBvirus(HBV),hepatitisCvirus(HCV), andhuman immunodeficiencyvirus(HIV) aremajorhealth problems. Among the 2billion people infected with HBV worldwide,morethan 350millionsuffer fromchronicHBV infection.1,2 The prevalence of HCV infection is reported
to be 2.3%---3% (130---170million people), of which 80% develop chronic infection.3,4 Additionally, WHO reported
that2millionpeoplewereinfectedwithHIVandthatthere were1.2milliondeathsrelatedtoAIDSin2014.5
Healthcare workers (HCWs) are at risk of transmitting blood---borne viruses, and surgeons have a higher risk of exposuretoblood andhigherrates ofpercutaneousinjury thanotherhealthcareworkers.6---8Itisestimatedthat16,000
HCV; 66,000 HBV and 1000 HIV infections have occurred worldwide in healthcare workers in 2000 as a result of occupationalexposuretopercutaneousinjury.8Transmission
ofblood---bornepathogenscanoccurviapercutaneousand mucocutaneousroutes,andsometimesviaexposuretoother bodyfluids.8,9
Septoplasty is amongthe 3 most commonly performed otolaryngological surgeries worldwide.10,11 It can be
per-formed under general or local anesthesia.12---14 The nose
--- andin particular theseptum --- is a vascular organand surgeonscommonlyencounterbleedingat somepoint dur-ingseptoplasty.Moreover,surgeonsgenerallyusesuturesto stabilizetheseptum,tostabilizetheperichondrium(using transfixionsutures)sothatnasalpackingisunnecessary,to preventsuchcomplicationsashematomaandbleeding,and
to close any septalmucosa tears.15,16 Turbinates are also
vascularorgansandturbinatesurgeryperformedwith sep-talsurgeryfurtherincreasesbleeding.17,18Thesefactorsare
associatedwithsurgeonexposure topatientbloodand/or secretions,which consequentlyincreasestheriskofblood bornevirustransmission,especiallyHBV,HCV,andHIV.19,20
AtourclinicpreoperativeserologicaltestingforHBV,HCV andHIVisperformedineveryadultpatientinwhich elec-tivesurgeryundergeneralanesthesiaisindicated,butnot inpatientsundergoingelectivesurgeryunderlocal anesthe-sia,includingseptoplasty.Theaimofthepresentstudywas todetermine theseroprevalence of HBsAg, anti-HCV, and anti-HIVinpatientsundergoingseptoplastywithandwithout turbinatesurgery,andtodetermineifpreoperativetesting forHBV,HCV,andHIVshouldalsobeperformedinpatients undergoingseptoplastywithandwithoutturbinatesurgery underlocalanesthesiaasanadditionalprecautiontoavoid exposuretopatientbloodandsecretionsduringsurgery.
Methods
This study included 3731 patients that underwent septo-plastywithandwithoutturbinatesurgerybetweenJanuary 2005andJuly2015.HBsAg,anti-HCV,andanti-HIV seropos-itivityinpatientsadmittedtotheOtolaryngologyClinicfor septoplasty with and without turbinate surgery was ret-rospectively analyzed. Preoperative blood samples were analyzedbyourhospital’smicrobiologydepartment.Patient age, gender, type of surgery, and serological data and hematologicalcountswererecorded.Thepatientswhohad
additionalsinonasalsymptomsandwhoseCTscanrevealed sinonasaldiseasehadendoscopicsinus surgery inaddition toseptoplastyandthuswereexcludedfromthestudy.
The study protocol was approved by the local Ethics Committee(18/12/2015-742),andwasconductedin accor-dancewiththeDeclarationofHelsinki.Datafrequencyand mean±SDwereanalyzed.
Statisticalanalysis
StatisticalanalysiswasperformedusingSPSSv.16.0for Win-dows(SPSS,Inc.,ChicagoIL).Descriptivestatisticsaregiven with each value’s Standard Deviation (SD). The normal-ity of the distribution of data was determined using the Kolmogorov---Smirnovtest.None ofthedatawerenormally distributed. Gender differences in age, and HBsAg, anti-HCV, and anti-HIV seropositivity were analyzed using the Mann---WhitneyU test. The level of statistical significance wassetatp<0.05.
Results
In total, 3731 patients underwentseptoplasty in the oto-laryngology department between 1 January 2005 and 31 December 2015. Among the patients, 3241 underwent surgerywithgeneralanesthesia,versus490withlocal anes-thesia.Preoperativeserologicaldatawereavailableonlyfor patientsthatreceivedgeneralanesthesia;thusly,all anal-yseswereperformedwiththese3241patients’data.Mean age ofthe patients was36years(range: 11---81years). In total,117(3.6%)patientswerepositiveforHBsAg,12(0.3%) werepositive foranti-HCV, and7(0.2%) werepositivefor anti-HIV. All 7 patients that were anti-HIV positive were referred for furtherconfirmation.Among the patients, 11 wereaged<18years,allofwhichwerenegativeforHBsAg, anti-HCV,anti-HIV.
Among the patients, 941 were female and 2300 were male.Inall,2%ofthefemalepatients(23/941)werepositive forHBsAg,versus4%ofthemales(94/2300).TheHBsAg pos-itivityratewassignificantlyhigherinmales(Mann---Whitney
U test, p=0.023). In total, 0.31% of the female patients (3/941)and0.39%ofthemalepatients(9/2300)were pos-itive for anti-HCV. All 7 patients that were positive for anti-HIVwere male. The anti-HIVpositivityrate was0.3% consideringonlythemalepatients.Theanti-HCVand anti-HIV positivity rates did not differ significantly between genders.SerologicalfindingsaresummarizedintheTable1.
No alteration or correlation was found between the hematologicalcounting(CompleteBloodCount)andthe pos-itivepatients.
Discussion
HBV,HCV,andHIVareimportanthealthcareproblems world-wide.Surgeonshaveahigherriskofexposuretobloodand higherratesof percutaneousinjurythantheother health-careworkers.6---8andthesignificantratesofmorbidityand
mortalityduetothesevirusessuggestsurgeonsshoulduseall precautionspossibletoavoidexposuretopatientbloodand secretionsduringsurgery.Percutaneousinjuryoccursduring manysurgicalprocedures,varyinginfrequencywithsurgical specialty,and the75% of blood---borne pathogenexposure occurs during surgery.20,21 It was reported that 5.5% of
percutaneousinjuriesoccurinotolaryngologicalpractice.21
The suture needle was reported to be the instrument mostassociatedwithpercutaneousinjury andexposure to blood---bornepathogens, accountingfor50% ofall surgical injuries,followedbysharpinstruments(34%)---primarilythe scalpelblade (6.9%); thesuture needle andscalpel blade are the 2 most commonly used surgical instruments dur-ingseptoplasty.20,21 Incision, suturing,wound closure,and
increasedbleedingareallassociatedwithsurgeonexposure tobloodandsecretions.20,21
ItwasreportedthatvaccinationagainstHBV,useof pro-tectiveglassesandgloves,doublegloving,andbluntsuture needles are the precautions necessary toprotect against blood and bodyfluid exposure.7,21---24 Whether or not
pre-operative testing of patients for HBV, HCV, and HIV can furtherdecreasetheriskof transmissionremainsunclear; incountrieswithlowinfectionrates,preoperativetestingis notcommonbecauseitisnotthoughttobecost-effective, whereasincountrieswithhighinfectionratesitisstrongly recommend that preoperative testing be performed.23,25
Transmissionofinfectionsviabloodoccursatahigherrate in developing countries than in developed countries, and occupationalblood exposure is ofgreat concernin devel-opingcountries.19 Turkey is adeveloping countryinwhich
theseropositivity rates were reported tobe 0.52%---4.19% forHBsAg,0.1%---1%foranti-HCV,and0%---0.1%foranti-HIV, andthepresentseroprevalencefindingsofthecurrentstudy aresimilartothosereportedearlierforTurkey.26---28Turkeyis
anintermediate-endemicregionforHBVandalow-endemic regionfor HCV.4,29---32 Moreover, HIV/AIDSis currently
con-sideredtobean emergingdiseaseinTurkey.33 As such,at
oursurgical departmentwe request preoperative serolog-icaltesting includingHBsAg, anti-HCV, andanti-HIV, inall patientsundergoingsurgeryundergeneralanesthesia.
Table1 SerologicaldataforHBsAg,anti-HCV,andanti-HIV.
Total Females(n=941) Males(n=2300) p
n % n % n %
HBsAg 117 3.6 23 2 94 4 0.023*
Anti-HCV 12 0.3 3 0.31 9 0.39 0.758
Anti-HIV 7 0.2 0 0 7 0.3 0.09
The preoperative prevalence of HBV in the present study’sseptoplastypatientswassignificantlyhigherinmales (4%) than in females (2%), as previously reported, which we think could be due greater social mobility and free-domamongmalesindevelopingcountries,especiallyinrural areas,makingthemalepopulationmoreproneto contract-ingtheinfection34,35;however,thereareotherstudiesfrom
developing countries showing higher rates of infection in females.36
Ourdepartment frequently performs septoplasty;3731 patients underwent the procedure with and without turbinate surgery between 2005 and 2015, of which 3241 receivedgeneralanesthesiaand490receivedlocal anesthe-sia.Localanesthesiaisasafeandcost-effectivetechnique forsinonasalsurgeryinselectedpatientswhenpaincanbe preventedand/ortreatedduringsurgery.12,37,38Our
depart-mentgenerallyusesgeneral anesthesiaduring septoplasty (3241 of 3731 patients) and all patients undergoing sep-toplasty under general anesthesia undergo preoperative serologicaltesting,includingHBsAg,anti-HCV,andanti-HIV; however,serologicaltestingisnotperformedinourpatients undergoingseptoplastyunderlocalanesthesia.Local anes-thesia is associated withless bleedingduring septoplasty thangeneralanesthesia37,38;however,bleedingcanstillbe
a problem for some patients under local anesthesia. Our patientsthatreceivelocalanesthesiagenerallyhaveahigh riskforgeneralanesthesia,includinghypertensivepatients andpatientsthatuseblood-thinnersforcardiacdisorders. These patients have a tendency for bleeding even under local anesthesia, putting the surgeon at risk of exposure toblood.Additionally,althoughlocalanestheticagentsare effectivepainrelievers,itisreportedthatnotallpatients aresatisfiedwiththepainmedicationtheyget fromlocal anesthesia.12Patientsthataresensitivetopaintendtomake
sharpmovementsinresponsetopainduringsurgery, jeop-ardizing positioning of the scalpel blade and sutures.14,39
Moreoverexperiencingpainincreasesbloodpressure, mak-ingpatientsmorepronetobleeding.Turbinatesurgeryalso increasestheriskofbleeding.Allofthesefactorsalsoare significant risk factors for surgeonexposure to blood and percutaneousinjuryduringseptoplastyunderlocal anesthe-sia,whichsuggeststhatpreoperativeserologicaltestingin patientsreceivinglocalanesthesiacouldberoutine.
WeobtaintheCTscanifthepatientreports any symp-toms related to sinus disorders. Of the patients who we obtainedCTscan,thepatientswhohadsinusdiseasewere excludedfromthestudy andhadendoscopicsinussurgery performedinadditiontoseptoplasty.Wewantedtoexclude thesebecauseweonly wantedtoincludethemostwidely performedprocedure(septoplasty)andmakethesurgeons awarethatalthoughitiscommonly performedanda rela-tivelyeasyandstraightforwardsurgery,itshouldbekeptin mindthateventhemostcommonandbasicsurgical proce-dureputsthesurgeonunderriskoftransmittingblood---borne pathogens.Whenthinkingaboutthe complicationsof sep-toplastyoranysurgery,transmissionoftheinfectionshould alwaysbekeptinmind.
As mentioned above, preoperative serological testing, includingHBsAg,anti-HCV,andanti-HIV,isperformedinall ofourpatientsundergoingsurgeryundergeneral anesthe-sia.Inadevelopingcountrywithahighprevalenceofthese viruses,suchtestingalertssurgeons,nurses,andtheentire
surgicalteamtotheneedforextracautionduringsurgery.In addition,preoperativeserologicaltestingfacilitates inform-ing our patients that are unaware of their seropositivity and early detection of infection in patients in which the associateddiseaseswouldotherwisegoundetected,which helps limit the spread of virus in the community. The presentstudy’sseropositivepatientswerereferredfor fur-therinvestigationandwereencouragedtotakeallnecessary precautions to prevent transmission to other individuals. These precautions areespecially important,asworldwide ahighproportionofoccupationallyacquiredHCV,HBV,and HIVinfectionsoccurindevelopingcountriessuchasTurkey, inwhichhealthcareworkersareexposedtoapatient popu-lationwithahigherprevalenceofblood---bornevirusesthan indevelopedcountries.19
None of the 7 patients who werepositive for anti-HIV wereawareof theirdiseasebeforethesurgery.Of the12 patientsthatwereanti-HCVpositive,onlyonepatientwas awareofhisresultsbeforethesurgery.Ofthe117patients thatwereHbSAgpositive,32patientswereawareoftheir resultsbeforetheirsurgery.Thesenumbersmaybesomehow unreliable, as these diseases can be sexually transmitted andthepeoplewhoknowtheyhavethedisease(especially HIV) maybereluctanttoexpressthattheyhavean infec-tious disease. This is important especiallyin conservative countrieswherepeoplewhohavethesediseases(especially HIVandHCV)mightbeexcludedfromthesociety.Itisa sur-geon’smostimportantresponsibilitytorespectthepatient confidentiality andtoreassure thepatientthat hisor her resultswillbekeptconfidential.Otherthanthat,wehave hadpatients whowerereluctanttoinform usabout their diseasebeforetheirbloodworkwaspositiveforinfection, whichwasmainlybecausetheythoughttheirdiseasewould resultincancelationoftheirsurgery.Thus,thesurgeonmust understandthepatientsconcernsandaddressanyquestions in their mindaccordingly. Also,we had patientswith low socioeconomicstatuswhoalreadywerediagnosedinother placesbeforeweobtainedbloodtestsfromthem.Theywere toldthattheyhadthediseaseintheplacetheywere diag-nosed,butfailedtounderstandordidnotpayattentionto it,thusdidnotinformusaboutthis.Thus,obtainingthese bloodworkscanbecrucialinincreasingpatientawareness, especiallyincountriesoflowsocioeconomicstatus.There maybemanyotherreasonsforthepatientstobereluctant totellasurgeonthattheyhave tothedisease.Forthese reasonsweobtainthesebloodworkonaroutinebasisfrom allourpatientswhoweperformsurgery.
For patients undergoing septoplasty under local anes-thesia, it might also be useful to perform preoperative serological testing, as septoplasty is also associated with the risk of contamination. It was reported that Turkish healthcareworkersinahospitalsettinghaveahighriskof percutaneousinjury/mucosalexposure,butoverall aware-nessofsuchriskislow.40 Althoughtheoccupationalriskto
healthcareworkers is lower in Turkey than insome other developingcountries,40---42studiesshowthatthereisahigh
incidenceoftheexposuretobloodbornepathogensin Turk-ishHCWs,ascomparedtodevelopedcountries.40,42---45Some
studiesindicatethatroutineserologicaltestingisnot neces-saryforallpreoperativepatients,butshouldbeperformed inpatientswithriskfactors.23Thisapproachcouldbe
has higher prevalences. Furthermore, overall awareness of percutaneous and mucocutaneous injury among Turk-ish healthcareworkers is low.40 Educational programsfor
increasing awareness of the risk in Turkish hospitals is of utmost importance and when combined with serological testing, such programs could be more effective and fur-therincreaseawareness.Tothebestofourknowledgethe present studyis thefirsttoassess theprevalence ofHBV, HCV,andHIVinfectionin patientsundergoingseptoplasty. Also,ourstudyincludesalargepatientpopulation.
Conclusion
Septoplastywithandwithoutturbinatesurgeryisassociated withtheriskoftransmissionofblood---bornevirus transmis-siontosurgeons,whetherperformedunderlocalorgeneral anesthesia. The present findings indicate that education ofhealthcareworkerscombinedwithroutinepreoperative serologicaltestinginpatientsundergoingseptoplastyunder generalandlocalanesthesiacouldfurtherincreasepatient andhealthcareworkerawareness,anddecrease contamina-tionrates.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Acknowledgements
Theauthorsdisclosenofinancialrelationshiprelevanttothis publication.
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