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 ~  Results
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 ~  References

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ORIGINAL ARTICLE
Year : 2004  |  Volume : 22  |  Issue : 3  |  Page : 159-165
 

Impact of the human immunodeficiency virus infection on emergency medicine department in a tertiary care hospital in India


Department of Microbiology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad - 500 082, Andhra Pradesh, India

Date of Submission03-Feb-2004
Date of Acceptance03-Mar-2004

Correspondence Address:
Department of Microbiology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad - 500 082, Andhra Pradesh, India

 ~ Abstract 

PURPOSE: To assess the impact of HIV infection on emergency medicine department services. METHODS: The demographic and clinical data of all the HIV reactive individuals admitted to the emergency medicine department (EMD) were analyzed by reviewing the case records retrospectively. RESULTS: Of the 1187 HIV reactive cases detected during a period of 10 years, 435 cases were admitted to the EMD. 90% of the patients were unaware of their HIV reactive status. Prolonged perplexing pyrexia was the commonest presentation (73.4%) followed by Tuberculosis (53%). Neurological complications, AIDS enteropathy were also seen to rise over the years. Road traffic accidents/polytrauma/an acute cardiac event contributed to 7.6% of the cases who otherwise had no symptoms related to the HIV infection. CONCLUSIONS: The rate of increase in HIV reactivity, among the patients presenting to the EMD assumes significance as they could potentially transmit HIV infection to the health care personnel following exposure to body secretions of the patient during resuscitation. The study emphasizes the importance of stringent practice of universal precautions irrespective of the HIV status by all health care workers at all levels, especially in the EMD.

How to cite this article:
Teja V D, Lakshmi V, Sudha T. Impact of the human immunodeficiency virus infection on emergency medicine department in a tertiary care hospital in India. Indian J Med Microbiol 2004;22:159-65


How to cite this URL:
Teja V D, Lakshmi V, Sudha T. Impact of the human immunodeficiency virus infection on emergency medicine department in a tertiary care hospital in India. Indian J Med Microbiol [serial online] 2004 [cited 2019 Dec 10];22:159-65. Available from: http://www.ijmm.org/text.asp?2004/22/3/159/11209


In serological surveys conducted by the centres for disease control (CDC), Atlanta,[1] 0.2% - 8.9% of the patients seeking emergency care and 0.1% - 7.8% of patients receiving acute-care were found to be HIV antibody positive. 63% - 65% of these patients were unaware of their HIV status. These studies recommended that HIV testing of patients attending the emergency medicine department (EMD) would potentially identify infected persons hospitalized for conditions other than HIV/AIDS. Knowledge of their HIV infection status would then allow infected persons to seek treatment for HIV infection, prophylaxis or therapy for the opportunistic infections. These measures may help delay the onset of AIDS.
As per our hospital data on HIV infection, 36.65% of the HIV reactive cases were from EMD. We analyzed the data on all patients who were reactive for HIV from the EMD of our Institute from 1993 to 2002 (10 years) to assess the impact of HIV on the EMD services, to study the spectrum of clinical illness induced by HIV infection among our patients, and to reiterate the need for preventive strategies and strict adherence to the universal precautions against blood borne pathogens.

 ~ Materials and Methods Top

The Nizam's Institute of Medical Sciences (NIMS) is a tertiary care hospital and University, which has all super speciality units. Its EMD functions 24 hours and receives patients not only from the local area but also from different parts of the state of Andhra Pradesh. The EMD is staffed 24 hours a day by residents from general medicine, orthopedics, surgery and emergency physicians, nurses and other ancillary staff. Residents from other specialities are on call.
All the tests for detection of HIV infection were carried out in the microbiology laboratory of the institute, which is a well established laboratory with all facilities to carry out immunoassays. As per the policy of the institute, the patients were counselled before blood samples were collected for screening for HIV whenever possible. All the serum samples sent for HIV testing were evaluated by the ELISA for HIV antibodies (initially only for HIV 1 and later, when the kits became available, for both HIV 1 and 2 antibodies). Each reactive specimen was re-evaluated by a second immunoassay and confirmed by Western blot test. The demographic and clinical data of all the HIV reactive individuals was analyzed by reviewing the case records. Risk factors that were recorded by the treating teams during history taking and/or in previous records were also analyzed.
There were 22 HCWs who sustained accidental needle stick injury while attending to HIV reactive patients. They directly reported to the microbiology department, where they were extensively counselled and were advised post exposure prophylaxis (PEP). None of these HCWs had seroconversion. On one occasion, the whole team of HCWs including anaesthetists and orthopedic surgeons were exposed to the blood and body fluids of a severely traumatized patient during resuscitation. The patient was later detected to have HIV infection. The team was counselled and advised PEP.

 ~ Results Top

Four hundred thirty five out of 1187 (36.67 %) HIV reactive cases recorded at the institute were patients admitted to the EMD during 1993 to 2002 (10 years). Only 48/435 (10%) patients knew of their HIV seropositive status prior to admission to the EMD. The rest of the patients (90%) were suspected to have an unrecognized HIV infection and were proven to be seropositive upon testing.
The proportion of HIV reactive cases from EMD from the total reactives at the institute, during these 10 years, showed a steady rise, from 15.8% in 1993 to 46.7% in 2002 [Figure - 1]. The number of EMD patients testing positive for HIV antibodies increased from 3 cases in 1993 to 92 cases in 2002. The average length of hospital stay per patient in the EMD was about 5 days.
[Figure - 2] and [Figure - 3] show the age and year wise distribution of the HIV reactives among males and females. Most of the cases were in the 31 - 40 years age group. However, it is interesting to note that in the past few years, the incidence of HIV reactive men and women in the higher age groups has increased. These individuals had sought EMD services for an acute cardiac event and were otherwise asymptomatic for HIV. However, a definite risk factor for HIV could be assessed in these patients, which was either a blood transfusion or heterosexual promiscuity.
Risk factors that were elicited among the HIV reactives are shown in [Figure - 4]. There were a large number of patients (203/435, 46.7%) in whom the history was not suggestive of any high risk behavior for HIV infection, in spite of repeated risk assessment by professional counsellors.
The clinical presentations were classified as symptomatic and asymptomatic for HIV induced illness. The disciplines to which these patients were admitted is shown in [Table - 1]. The total symptomatic cases during these 10 years were 319 / 435 (73.35%) while the asymptomatic cases were 116 / 435 (26.67 %). A rise was seen in both the groups over the years [Figure:5].
The commonest presentation was prolonged pyrexia [Table - 2] with an acute event like respiratory distress, seen in 234 out of 319 patients (73.4%). These patients also had other symptoms of an AIDS defining illness like unexplained loss of weight and appetite, persistent cough, lymphadenopathy, chronic diarrhoea etc. The incidence of neurological complications, gastrointestinal presentations and AIDS related enteropathy were seen to rise over the years from 1.9% in 1993 to 14% in 2002. Dermatological conditions and oral lesions were not the primary reason for consultation. Sixty out of 319 (18.81%) of the patients had a full spectrum of AIDS related illness. A mortality rate of 12.54% (40/319) was documented in these patients.
The incidence of infections was also significant [Table - 3]. The diagnosis was based on microbiological or serological evidences. Tuberculosis (TB) was the most common infection documented (169/319, 53%). Out of these, pulmonary TB was the most common presentation, seen in 81 out of 169 (47.9%) cases [Table - 4]. There was 100% mortality in patients with disseminated TB.
Among the opportunistic infections, most of the cases with toxoplasmosis presented as encephalopathy or multiple brain abscesses resulting in fits and dementia. One of the patients with cryptococcal meningitis was a 14 year old haemophiliac boy who had transfusion related HIV infection. He succumbed to the Cryptococcus infection. Pneumocystis carinii pneumonia was strongly suspected clinically in 35 cases with a good response to co-trimoxazole. The asymptomatic group included 115 patients. Ninety-seven of the patients came to the EMD as they either had sustained a road traffic accident or other trauma (e.g., spinal cord injury) or had an emergency cardiac event. In all these patients, the HIV status was unknown prior to admission and no risk assessment could be made as they were in a critical condition. All of them needed immediate resuscitation or interventions. Remaining 19 patients were haemophiliacs requiring an urgent blood transfusion for an acute bleed. The only risk factor identified in this group was a history of multiple blood transfusions.

 ~ Discussion Top

Data from major institutes like the John Hopkins institute[2],[3] predicted that the impact of HIV would steadily increase on the EMD of any institute. Our study also shows that HIV infection has a direct and significant impact on the emergency services,[2],[3] particularly as patients with unrecognized but symptomatic HIV infection increasingly require hospital admission. The documented rate of HIV infection among patients who tested reactive for HIV antibodies at our institute is steadily increasing (0.77% in 1993 to 7.9% in 2002). The rate of HIV reactivity among the EMD patients is also significantly on the rise. And as these prevalence rates increase and the infection spreads, the potential for occupational transmission will also be seen to rise.[4],[5]
The HCWs in EMD may have the most exposure from patients with unrecognized HIV infection, like the severely traumatized and heavily bleeding patient needing urgent resuscitation.[2],[6],[7],[8],[9] Several studies have observed that universal precautions were strictly followed by all the HCWs only when patient was known to be seropositive. However, patients with unknown HIV status were handled with no special measures and no precautions were followed.[2],[6],[7],[8],[9]
Most discussions on HIV testing reached a conclusion on whether testing should be encouraged at least in populations in which the prevalence of infection with the virus is high. As per the CDC recommendations, routine testing of patients for HIV has been recently advocated as a means of increasing provider vigilance and reducing occupational exposures.[1]
Hospitals should be aware of the prevalence of HIV in the populations that they serve, so that they can better provide HIV counselling and testing.[10] If hospitals find high rates of HIV/AIDS, and they have populations of patients who are not aware of their own status then routine testing can be very helpful in making patients aware of their infection, and also help hospitals offer appropriate treatment and counselling.[10] Any hospital with a HIV seroprevalence rate of at least 1% or an AIDS diagnostic rate of 1/1000 discharges should strongly consider adopting a policy of offering counselling and testing routinely to patients aged 15-45 years.[1],[10] Following these recommendations of CDC in 1993,[1] several hospitals in the developed countries, started testing for HIV in high prevalence areas. These studies documented that routine HIV testing in clinical settings helps to target high prevalence communities, destigmatize HIV testing and better link HIV infected persons to care and prevention services.[9],[10]
It is critical that the primary care or emergency physician considers the diagnosis of HIV infection when appropriate and performs the necessary tests to make the diagnosis. As can be seen from the spectrum of disease presentations in our study, the range of specific and nonspecific conditions associated with HIV is vast. Hence it is justified that, whenever a patient presents with an unexplained illness or persistent nonspecific symptoms, HIV infection must be included in the differential diagnosis. This would facilitate early diagnosis and appropriate management.[11]
Though earlier studies showed that risk factor assessment in the EMD patient is limited, our study indicates that if consistently applied, majority of the infected patients can be identified at entry. However, the assessment may not be possible in patients with severe trauma, massive bleeding, cardiac or central nervous system emergencies. The need for prompt invasive interventions may render details of risk factor assessment unimportant.[12]
Because a large number of HIV-infected individuals are unaware of their infection, it is critical that all clinicians assess risk for HIV and offer testing when appropriate.[1],[10],[13],[14] The risk factor assessment should focus more on “risk behaviors” rather than “risk groups”. A thorough history taking, including nonjudgmental but specific questioning about sexual activity and drug use, has become even more important in identifying patients at risk for HIV infection.[13],[15] In our study, 119 out of 435 of the HIV reactive patients had a heterosexual promiscuity. Some of the patients (23/435) acquired the infection through blood transfusion. But a large number were (293/435, 67%) unaware of their HIV status. They presented to the EMD for unexplained illness or trauma.
Unlike in developed nations, health care facilities in the developing countries suffer tremendously from lack of proper infrastructure and facilities to follow universal precautions, low levels of awareness about safety precautions and a certain degree of complacency amongst the medical and health care personnel. These are some of the important concerns, which should be addressed, studied and appropriate measures should be properly implemented.
Majority of the patients who presented to our EMD did not know their HIV status. Also, though our data shows that one can suspect a HIV infection from the clinical presentation, all patients infected with HIV or other pathogens cannot be reliably identified, especially if they are in the asymptomatic phase of the disease. Hence, infection control practices should be consistently applied, particularly in the EMD setting by all HCWs. regardless of the HIV status or presence of risk factors.[16] It should be realized that, there is no justification for taking any discriminatory measures of safety based on the fact that a person is suspected or known to be HIV infected, as some patients may be in the window period of infection and may be non reactive for HIV antibodies but can very much transmit the disease.[2],[3],[4],[5],[7],[9],[12]
Therefore, it becomes more and more important for all the HCWs to practice all the universal and biosafety precautions at all times for all patients.[4] HIV infection can be greatly reduced by practicing infection control guidelines strictly. These include hand washing and use of personal protection, maintenance and use of work areas, precautions while handling contaminated equipment, following work practice controls, training of the staff, having a check on the proper disposal of waste, and good medical surveillance.[1],[4],[8] Our study emphasizes the need for stringent practice of universal precautions irrespective of the HIV status, by all emergency HCWs at all levels.
Though the estimates of the UNAIDS show a low HIV prevalence rate (0.7%), the overall number of people with HIV infection is high. And as the prevalence rates increase and the infection spreads, occupational transmission will occur more frequently. Hospitals should therefore focus on policies for reducing transmission, specifically on clear standards of occupational safety and health. At the same time, strategies must be designed for increasing compliance with such guidelines.[13] Hospital administrators should create awareness amongst staff about the safety precautions by conducting seminars, sessions, and training programs from time to time.
The care of HIV/AIDS patients places a large economic and manpower burden on emergency care services. Governments, health policy officials, hospital and emergency department administrators should plan for the appropriate use of emergency services so that both HIV infected patients and the other emergency department patients will be adequately served. 

 ~ References Top

1.Centre for Disease Control and Prevention. Recommen-dations for Human Immunodeficiency Virus Testing services for in-patients and out-patients, in Acute Care Hospital Settings-Recommendations and reports. MMWR1993;42 (RR-02).  Back to cited text no. 1    
2.Baker JL, Kelen GD, Siverston KT, Quinn TC. Unsuspected Human Immunodeficiency Virus in critically ill emergency patients. JAMA 1987; 257(19):2609-2611.  Back to cited text no. 2    
3.Kelen GD, Di Giovanna T, Bisson L, Kalainov K, Silvertson KT, Quinn TC. Human immunodeficiency virus in the emergency department patients. Epidemiology, clinical presentation and risk to Health Care Workers : The John Hopkins experience. JAMA 1989;262(4):516-522.  Back to cited text no. 3    
4.Emergency Nurses' Association Position Statement - Blood-borne Infectious diseases. www.ena.org/services/posistate/data/bloinf.html.  Back to cited text no. 4    
5.Gabor DK. Special considerations for Emergency Medicine Personnel. In AIDS, Biology, Diagnosis, Treatment and Prevention. 4th Edition edited by Vincent T. Devita, Jr. Samuel Hellman and Steven A. Rosenberg, Lippin Cot - Raven. Publishers 1997:685-694.   Back to cited text no. 5    
6.ALEC Action Weekly report - Health Care Professionals. www.alec.html.  Back to cited text no. 6    
7.Kelen GD, Fritz S, Qaqish B, Brookmeyer R, Baker JL, Kline RL, Cuddy RM, et al. Unrecognized HIV infections in emergency department patients. N Engl J Med 1988;318(25):1645-1650.  Back to cited text no. 7    
8.Madan AK, Rentz DE, Wahle MJ, Flint LM. Non compliance of health care workers with universal precautions during trauma resuscitations. South Med J 2001;94(3):277-280.  Back to cited text no. 8    
9.Nagachinta T, Gold CR, Cheng F, Heseltine PN, Kerndt PR. Unrecognized HIV-1 infection in inner-city hospital emergency department patients. Infect Control Hosp Epidemiol 1996;17(3):174-177.  Back to cited text no. 9    
10.Beltrami JF, Franko EA, Tooney KE. Human Immunodeficiency Virus seroprevalence trends: five hospitals in South Georgia, 1993 through 1997. South Med J 2001;94 (4):421-426.   Back to cited text no. 10    
11.Moran GJ. Managing the Human Immunodeficiency Virus related Medical Emergencies. Emergency Medicine 1995;18-30.  Back to cited text no. 11    
12.Beltrami EM, Williams IT, Shapiro CN, Chamberland ME. Risk and Management of Blood-Borne Infections in Health Care Workers. Clin Microbiol Rev 2000;13(3):385-407.  Back to cited text no. 12    
13.Brennan TA. Transmission of Human Immuno-deficiency Virus in the health care setting - Time for action. N Engl J Med 1991;324(21):1504-1509.  Back to cited text no. 13    
14.Centre for Disease Control and Prevention. Routinely recommended Human Immunodeficiency Virus Testing at an urban urgent Care clinic - Atlanta, Georgia, 2000. MMWR 2001;50(25):538.  Back to cited text no. 14    
15.Rhame FS, Maki DG. The case for wider use of testing for Human Immunodeficiency Virus infection. N Engl J Med 1989;320(19):1248-1254.  Back to cited text no. 15    
16.Ronald K. Emergency care workers warned of risks from blood. Chicago Tribune, 1987.  Back to cited text no. 16    
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