Original Article
Hepatitis B and Hepatitis C in Emergency Department Patients
N Engl J Med 1992; 326:1399-1404May 21, 1992
- Abstract
- Abstract
Background.
Infections with hepatitis B virus (HBV), hepatitis C virus (HCV), and the human immunodeficiency virus type 1 (HIV-1) are common in inner-city populations, but their frequency and interrelations are not well established.
Methods.
During a six-week period, excess serum samples were collected, along with information on risk factors, from all adult patients presenting to an inner-city emergency department. The samples were assayed for hepatitis B surface antigen (HBsAg) and antibodies to HCV and HIV-1.
Results.
Of the 2523 patients tested, 612 (24 percent) were infected with at least one of the three viruses. Five percent were seropositive for HBV, 18 percent for HCV, and 6 percent for HIV-1. HCV was found in 145 of the 175 intravenous drug users (83 percent), 36 of the 171 transfusion recipients (21 percent), and 5 of the 24 homosexual men (21 percent). Among black men 35 to 44 years of age, the seroprevalence of HCV was 51 percent. HBsAg was present in 9 percent of those whose only identifiable risk was possible heterosexual exposure. At least one viral marker was found in about 30 percent of the patients who were actively bleeding or in whom procedures were performed. Testing for HIV-1 alone would have failed to identify 87 percent of the patients infected with HBV and 80 percent of those infected with HCV.
Conclusions.
In a population of patients in an innercity emergency room, HBV, HCV, and HIV-1 are all highly prevalent. However, routine screening for HIV-1 alone would identify only a small fraction of the patients who pose risks of severe viral infections, including HBV and HCV, to providers. (N Engl J Med 1992;326:1399–404.)
Media in This Article
Figure 1
Smoothed Seroprevalence Curves for Antibody to HCV (Panel A) and for HBsAg (Panel B) among 2523 Patients in the Emergency Department.Table 1
Seroprevalence of Viral Markers among 2523 Patients in the Emergency Department, According to Risk Factors.Article Activity
- Article
IN addition to human immunodeficiency virus type 1 (HIV-1), hepatitis B virus (HBV) and hepatitis C virus (HCV) are major sources of public health concern. Approximately 25 percent of adults infected with HBV become ill with jaundice, and of the 6 to 10 percent with acute infections who become carriers, about a quarter progress to chronic active hepatitis.1 In a substantial proportion cirrhosis or primary hepatocellular carcinoma develops. HCV is considered to be the chief etiologic agent for both parenterally transmitted2 3 4 and sporadic5 6 7 non-A, non-B hepatitis. Although HCV infection is usually not severe and is often asymptomatic, chronic hepatitis develops in at least 50 percent of those infected, and at least 10 percent will die of associated complications.8 The presence of antibody to HCV is particularly associated with chronic liver disease in persons with post-transfusion non-A, non-B hepatitis,9 and it may also be associated with more severe alcoholic liver disease10 , 11 and the development of hepatocellular carcinoma.10 , 12 13 14
HBV, HCV, and HIV-1 share modes of transmission and are relatively prevalent among certain population groups. However, their seroprevalences and interrelations in a general inner-city population of patients have not been described. Also, since parenteral transmission appears relatively efficient for these viruses, percutaneous exposure represents an occupational risk to health care providers. Routine testing of patients for HIV-1 has recently been advocated as a means of increasing provider vigilance and reducing occupational exposures.15 , 16 However, a strict focus on routine HIV-1 testing may not identify patients with other transmissible blood-borne infections, such as HBV and HCV.
We previously reported a high seroprevalence of HIV-1 infection (6.0 percent) among patients in our emergency department.17 We now describe the seroprevalence and epidemiologic characteristics of HCV and HBV among 2523 patients in the emergency department and examine the interrelations among active HCV, HBV, and HIV-1 infections. We also assess the potential value of routine testing of patients only for HIV-1 in this setting as a means of identifying those who pose a risk of HBV or HCV to providers.
Methods
The facility and study design have been described previously in a report on the seroprevalence of HIV-1 in our emergency department population.17 Briefly, for six consecutive weeks from June through August 1988, excess serum was retained from all patients 15 years of age or older who presented to the emergency department at Johns Hopkins Hospital and had blood drawn. Serum samples and data were collected prospectively with a procedure in which the patient's identity was not linked with the sample. Serum specimens and corresponding data-collection sheets were labeled with preassigned study numbers that did not contain any patient identifiers. Data were collected 24 hours a day during the patients' visits by study investigators who were not involved in the patients' care. The serum samples were analyzed for antibody to HIV-117 and for hepatitis B surface antigen (HBsAg), and subsequently, when assays for HCV became available, for antibody to HCV. The study design was approved by the institution.
Data on demographics, clinical condition, procedures performed, observed exposures of providers to the patient's blood and body fluids, and risk factors were collected for each patient. At the time of the study, it was routine policy in the emergency department to inquire about risks for blood-borne infections, with HIV-1 transmission used as a model. Thus, the risk factors ascertained were any history within the past 10 years of intravenous drug use, homosexual or bisexual activity in men, receipt of blood products, or heterosexual activity with a partner who had any of the foregoing risk factors. The risk factors were determined by a study investigator (not involved in the patient's care) who interviewed each patient directly; the interview was supplemented by a review of the patient's chart. The risk factors were categorized as being present, absent (the category that was used when a patient denied having a risk factor), or of unknown status. The last category was used in the case of patients for whom no risk factors were found but whose medical condition precluded a full assessment of risk. Unprotected exposures of providers to patients' blood and body fluids were monitored prospectively by direct observation, and this information was supplemented in interviews with the providers.
Serologic Analysis
Serum samples were frozen and stored at — 70° C. They were each evaluated by enzyme-linked immunosorbent assay (ELISA) for antibodies to HIV-1 (Organon-Teknika, Charleston, S.C.), and all repeatedly reactive specimens were analyzed by Western blotting for reactivity with HIV-1 protein (Dupont, Wilmington, Del.). Specimens with multiple antibody bands reactive to p24, p31, and gp41 or gp120/160 were considered seropositive.
Antibody to HCV was detected by the first-generation assay Ortho HCV ELISA Test System (Ortho Diagnostics, Raritan, N.J.).6 All samples repeatedly reactive were tested further by an HCV dot blot immunoassay (Matrix HCV, Abbott Laboratories, Abbott Park, Ill.). The Matrix HCV antigen test panel consists of recombinant antigens that represent three nonoverlapping regions of the HCV genome: C100 (a nonstructural gene 4 product), 33c (a nonstructural gene 3 product), and core (viral nucleocapsid). Samples were considered positive if two or more distinct antigens were reactive, negative if there were no reactive antigens, and indeterminate if the reactivity pattern did not meet either of these criteria.18
Samples reactive for antibodies to HCV were also analyzed by the recombinant immunoblot assay system (RIBA-1, Ortho Diagnostics).19 Samples were considered positive if both the C100–3 and 5–1–1 bands were present. A sample was considered indeterminate if there were bands present but the criteria for reactivity were not met or if the control band of Superoxide dismutase was reactive along with the C100–3 band, the 5–1–1 band, or both.
HBsAg was detected with the NML ELISA (Organon-Teknika, Durham, N.C.). All repeatedly reactive specimens were considered positive for HBsAg.
Data Analysis
Comparisons were made by the chi-square test for proportions and the test of independence, Fisher's exact test, or Student's t-test. Seroprevalence rates specific to age and race were analyzed by grouping the patients in 10-year age intervals and calculating the age-specific seroprevalence rate for each interval. These rates were then plotted at the midpoints of the intervals. Seroprevalence curves were obtained by smoothing the original ungrouped data with a smoothing technique.20 Unlike the method used in our previous studies,17 , 21 risk factors were not ordered hierarchically, because the resulting hierarchy may be different for each type of viral infection, rendering comparison difficult. Thus, risk factors were categorized according to whether the patient had a single risk factor, had multiple risk factors, acknowledged no risk factors, or had no identified risks but incomplete ascertainment of risk factors. Multivariate logistic-regression analysis was performed to determine which characteristics of patients were independently associated with each viral infection.22 The method used also allowed the estimation of pairwise association among the three markers after adjustment for the effects of covariates on each.22
Results
There were 5229 visits by patients to the emergency department during the study. Among these patients, 2613 had blood drawn, but 90 patients had insufficient excess serum samples for all analyses to be completed. Thus, there were 2523 patients in the study sample. Of these, 1216 (48 percent) were men, and 1307 (52 percent) were women. There were 1947 blacks (77 percent), 559 whites (22 percent), and 17 members of other races (<1 percent). Thirty-three percent of the patients were admitted to the hospital.
Seroprevalence of Viral Markers
Six hundred twelve patients (24 percent) had at least one viral marker. There were 458 serum samples positive for HCV (18 percent), 129 positive for HBsAg (5 percent), and 152 positive for HIV-1 (6 percent) (Table 1Table 1
Seroprevalence of Viral Markers among 2523 Patients in the Emergency Department, According to Risk Factors.). Of the patients with HIV-1 infection only, 57 (38 percent) knew they were infected. Only 4 of those with HBsAg (3 percent) and 16 of those with HCV (3 percent) presented with clinical evidence of possible liver disease (jaundice, hepatomegaly, or ascites).The mean (±SD) age of the patients was 43±19 years, and the ages of those with HBsAg, HCV, and HIV-1 were 41±18, 37±13, and 34±8 years, respectively. Race- and sex-specific curves of seroprevalence plotted against age are shown in Figure 1Figure 1
Smoothed Seroprevalence Curves for Antibody to HCV (Panel A) and for HBsAg (Panel B) among 2523 Patients in the Emergency Department.. The highest seroprevalence rate for HCV (51 percent) was found among black men 35 to 44 years of age. In this group, 58 percent were infected with at least one of the three viruses. Among whites, the highest rate of HCV seroprevalence (21 percent) was also found among men 35 to 44 years old. The highest seroprevalence rate for HBsAg was found among black men 55 to 64 years old (10 percent) and over 84 years old (11 percent) (Fig. 1). Logistic-regression analysis revealed that persons 25 to 34, 35 to 44, and 55 to 64 years old had significantly higher seroprevalence rate's for HCV than those over 64 years old (Table 2Table 2
Multivariate Logistic-Regression Analysis of Seropositivity for HBsAg and Antibody to HCV among Patients in the Emergency Department.). The prevalence of HBsAg did not vary significantly with age.In 91 specimens there was evidence of infection with both HCV and HIV-1 (odds ratio, 8.1; 95 percent confidence interval, 5.8 to 11.5), and in 17 there were infections with both HIV-1 and HBsAg (odds ratio, 2.5; 95 percent confidence interval, 1.5 to 4.3). The hypothesis of independent distributions was rejected for each of these two relations (P<0.001). This hypothesis could not be rejected in the case of the 30 persons infected with both HCV and HBsAg (odds ratio, 1.4; 95 percent confidence interval, 0.9 to 2.1; P = 0.12). The multivariate logistic-regression model revealed that once other covariates were taken into account, none of the three associations were statistically significant (Table 2). Although more coinfections occurred than would have been predicted by the seroprevalence rates observed, infections with HBsAg and HCV each occurred more often in the absence of other infections. A total of 460 patients (18 percent) had either HCV or HBsAg without concurrent HIV-1 infection. Testing for HIV-1 antibody alone would have missed 367 of 458 patients with HCV infection (80 percent) and 112 of 129 carriers of HBsAg (87 percent). Overall, testing for HIV-1 would have failed to identify 460 of 629 patients (73 percent) with at least one infection other than HIV-1.
Seroprevalence According to Risk Factors
Seroprevalence rates of HCV, HBsAg, and HIV-1 in the population stratified according to risk factor are shown in Table 1. Intravenous drug users had particularly high rates of viral infection, particularly with HCV (83 percent). Persons with homosexual activity as their only risk factor had relatively high rates of all three viral markers, with 79 percent having evidence of at least one viral infection. Relatively high rates of infection were also found among those whose only acknowledged risk factor was heterosexual exposure; at least one marker was found in 23 percent. Even the group of those with no identified risks had relatively high rates of infection with each virus. Multivariate logistic regression revealed that the only risk independently associated with HBsAg was homosexuality, whereas both intravenous drug use and the receipt of blood products were associated with HCV (Table 2).
We examined whether the presence of HIV-1 increased the likelihood of coinfection with either HCV or HBsAg for patients in the various risk categories. No increase in the prevalence of either virus was found among those in single-risk categories (P>0.2). The regression analysis that addressed these associations in those with multiple risk factors had similar results (Table 2).
Potential Exposure of Health Care Providers to Viral Infection
The incidence of unprotected exposure to patients' blood or body fluids was assessed for 98 percent of the patients. Situations that placed providers at increased risk occurred in significant numbers (Table 3Table 3
Potential Exposure of Health Care Providers to Virus from Patients.). Routine testing only for HIV-1 would have missed 74 to 88 percent of infections with HCV or HBsAg among patients posing particular risks of exposure to providers. Of the unprotected (nonpercutaneous) exposures of providers to infected blood or body fluids, 88 percent and 75 percent, respectively, involved viruses other than HIV-1. Routine testing only for HIV-1 would have missed 11 of 14 viral infections (79 percent) among those requiring immediate major surgery. Screening for HBsAg in addition to HIV-1 would still have failed to identify 10 such patients who had HCV infection only (71 percent).Discussion
We found high seroprevalence rates of HBsAg, HCV, and HIV-1 among the patients in our emergency department in inner-city Baltimore. Nearly 25 percent of the patients were actively infected with at least one of these viruses. Although general serologic surveys of HCV have been undertaken23 , 24 and high seroprevalence rates of HCV have been reported among specific risk groups, such as intravenous drug users 25 , 26 there are few data on HCV in inner-city populations. The 18 percent HCV seroprevalence rate found in this study represents one of the highest rates reported in a general population of patients. We found that HCV was concentrated among patients 25 to 44 years old, with a particularly high prevalence among minorities, as noted in a previous study.24
The seroprevalence of HCV among intravenous drug users (83 percent) was similar to that found by others in the Baltimore—Washington, D.C., area.25 Among the men who acknowledged homosexual activity as their only risk factor (21 percent), HCV seroprevalence was higher than that suggested by other studies,3 , 25 , 27 28 29 and this may indicate an increasing spread among this risk group in our area. Although some studies suggest that heterosexual exposure to HCV is not a major risk factor for transmission,29 , 30 our data support the findings of others that such transmission can be considerable, even if less efficient than that occurring by other routes.3 , 5 , 27 , 28 , 31 , 32 Still, among those with possible heterosexual exposure as their only risk factor, HCV seroprevalence was comparatively lower than in other risk groups. Heterosexual exposure may have been underdetected, however, and it may thus be responsible for infections found among those with no identified risks.33 Unreported intravenous drug use may also explain some of these infections, as well as those occurring in other risk groups. Still, the high proportion of patients infected with HCV in whom we did not identify a possible source of exposure (40 percent) was similar to that reported in the literature.5
The seroprevalence of HBsAg among our patients (5 percent) was also one of the highest reported for a general population of patients,34 , 35 a finding that supports calls for programs of universal vaccination.36 HBsAg was most commonly found among black men (6 percent), although neither race nor sex was independently associated with it. The seroprevalence of HBsAg among patients in our risk groups was similar to that observed in the Veterans Affairs study conducted near Baltimore.34
The issue of routinely testing patients for HIV-1 as a means of identifying those who may pose a risk of infection in an occupational setting has received considerable attention.15 , 16 We found, however, that almost 20 percent of our patients had active HBV or HCV infection without concurrent HIV-1 infection. Testing for HIV-1 antibody alone would have missed 367 of all the HCV infections (80 percent) and 112 of those with HBsAg (87 percent). It should be noted that almost a third of the patients who went directly from the emergency department to the operating suite were found to have at least one viral infection, and the vast majority of these (79 percent) would not have been identified by routine screening for HIV-1 alone (Table 3). As we found with HIV-1,17 patients with HBsAg or HCV cannot be reliably identified on the basis of patient-associated characteristics, risk assessment, or clinical presentation. Clinical condition appears to be the least helpful, since only 3 percent of those with HBsAg and 3 percent of those seropositive for HCV had evidence of liver disease. Given the wide distribution of these viruses in this population, routine HIV-1 testing would be relatively ineffectual as a means of alerting providers to patients who may pose an occupational risk. Adherence to universal precautions remains the best strategy for this purpose.
We chose to assay for antibodies to HlV-1, HCV, and HBsAg because the presence of each of these markers implies the ability to transmit virus.1 , 2 , 4 , 6 , 37 38 39 40 Thus, some assessment of the potential risk to providers from contact with these viruses could be undertaken. The potential for the exposure of providers and subsequent transmission of viral infection in this setting is considerable (Table 3). During the six weeks of our study, we documented more than 4000 major and minor invasive procedures, and 477 of the patients were actively bleeding. The annual risk of HIV-1 acquisition in an emergency department such as ours, where there is a high potential for exposure to this virus, has been estimated at only 0.026 percent per provider.41 However, the cumulative risk of occupational acquisition of HIV-1 over the course of a 30-year career in an environment such as ours has been estimated to be 1.4 percent (90 percent confidence interval, 0.2 percent to 14.0 percent) — a figure that is not inconsequential.42 Consistent adherence to universal precautions would decrease this risk by an estimated 30 percent.42
The rate of occupational acquisition of HBV among unvaccinated health care providers may be approximately 50 to 100 percent higher than the rate for HIV-1, since the risk of transmission after percutaneous exposure to HBsAg-positive blood can be as high as 30 percent.43 The prevalence of markers of HBV infection among unvaccinated providers who come into frequent contact with blood ranges from 15 percent to 30 percent — 3 to 10 times higher than in providers without much contact with blood.1 Unvaccinated personnel in the emergency department are at particular risk: 30 percent have been shown to have markers for HBV, the highest such rate of any group of providers.44 , 45 HBV transmission in the workplace remains a concern despite the availability of a vaccine. Only 50 percent of physicians in the United States46 and only 42 percent of all providers with responsibilities for patient care47 are believed to be vaccinated for HBV at this time.
The risk of occupational acquisition of HCV is only now being assessed. However, there have been several cases of such transmission in an occupational setting.48 49 50 A recent study reported that acute HCV infection with seroconversion occurred in 3 of 110 providers (2.7 percent) who had documented needle-stick exposures to the blood of patients with antibodies to HCV.49 Before the advent of HCV assays, there were several reports of occupational transmission of non-A, non-B hepatitis,51 , 52 and others have noted that this form of hepatitis appears to be more frequent among providers involved in patient care or those who have laboratory responsibilities than in control populations.5 , 27 , 28
This study has some limitations. Although we found the seroprevalence of HCV among our patients to be high, we may in fact have underestimated it. The time required for seroconversion can be long,4 , 6 and the first-generation screening assay used may have failed to identify some infected patients with low titers of antibodies or with antibodies to other antigens of HCV.53 The transfusion of blood seronegative for HCV has resulted in the transmission of HCV, with seroconversion in patients who subsequently had posttransfusion non-A, non-B hepatitis.2
The data on risk factors should be approached with some caution. In the absence of specific indications, providers rarely evaluate specific risk factors for viral hepatitis in the emergency department. Also, the assessment of other risk factors in such settings is limited, and thus some patients with infections but without identified risks may in fact have engaged in risky behavior or activities.33 Also, infection rates among members of risk groups presenting in our emergency department may not represent the rates in the population at large. Still, the proportion of members of risk groups who were infected with HCV or HBsAg and in whom no risks were identified was similar to that found in other surveys. 5 , 25 , 26 , 31 , 32 , 34
In summary, this study provides evidence of a high prevalence of presumed infectivity of HCV and HBV in an unselected but well-defined population of patients who also have a high prevalence of HIV-1 infection. The study also provides preliminary evidence that sexual transmission of HCV may be more common than has been previously appreciated. Exposure to HCV, HBV, and HIV-1 in health care settings in the inner city may be considerable without appropriate infection-control procedures. Apart from the clinical sequelae, the acquisition of any of these viruses may prevent providers from continuing to practice their professions,54 as recent developments attest. We believe that our data demonstrate the inability of routine HIV-1 screening to identify most patients who pose a risk to providers in such settings, and thus underscore the need for rigorous adherence to universal precautions and for continued implementation of HBV vaccination programs.
Supported by grants from the W.M. Keck Foundation and the Emergency Medicine Foundation.
We are indebted to Richard Kline, M.Sc., of the Laboratory of Immunoregulation, and Doris Wong, B.S., of the Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health; and to David Vallari of Abbott Laboratories, for their assistance with serologic analyses of specimens for antibody to HCV.
Source Information
From the Divisions of Emergency Medicine (G.D.K., G.B.G., K.T.S.) and Infectious Disease (T.C.Q.), Johns Hopkins University School of Medicine, and the Department of Laboratory Medicine (D.W.C.), Johns Hopkins Hospital, Baltimore; the Department of Biostatistics (B.F.Q.), University of North Carolina, Chapel Hill; and the Laboratory of Infectious Diseases (R.H.P.), and the Laboratory of Immunoregulation (T.C.Q.), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md. Address reprint requests to Dr. Kelen at the Department of Emergency Medicine, Marburg B186, Johns Hopkins Hospital, 600 N. Wolfe St., Baltimore, MD 21205.
- References
References
1
Protection against viral hepatitis: recommendations of the Immunization Practices Advisory Committee (ACIP) 2
Esteban
Full Text | Web of Science | Medline3
Esteban
CrossRef | Web of Science | Medline4
Alter
Full Text | Web of Science | Medline5
Alter
CrossRef | Web of Science | Medline6
Kuo
CrossRef | Web of Science | Medline7
Hopf
CrossRef | Web of Science | Medline8
Dienstag
Web of Science | Medline9
Mosley
CrossRef | Web of Science | Medline10
Nalpas
CrossRef | Web of Science | Medline11
Pares
CrossRef | Web of Science | Medline12
Sakamoto
Web of Science | Medline13
Colombo
CrossRef | Web of Science | Medline14
Kew
CrossRef | Web of Science | Medline15
Rhame
Full Text | Web of Science | Medline16
Angell
Full Text | Web of Science | Medline17
Kelen
CrossRef | Web of Science | Medline18
Vallari
Web of Science | Medline19
Weiner
CrossRef | Web of Science | Medline20
Watson 21
Kelen
Full Text | Web of Science | Medline22
Liang 23
Blood transfusion and the transmission of HCV. In: Proceedings of the First International Symposium on Hepatitis C Virus, Chapter II. Raritan, N.J.: Ortho Diagnostic Systems, 1989.
24
Stevens
CrossRef | Web of Science | Medline25
Donahue
Web of Science | Medline26
Williams
Web of Science | Medline27
Alter
CrossRef | Web of Science | Medline28
Alter
CrossRef | Web of Science | Medline29
Melbye
CrossRef | Web of Science | Medline30
Everhart
Web of Science | Medline31
Hess
CrossRef | Web of Science | Medline32
Tor
CrossRef | Web of Science | Medline33
Liddle
Web of Science | Medline34
Gordin
CrossRef | Web of Science | Medline35
Handsfield
CrossRef | Web of Science | Medline36
Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: recommendations of the Immunization Practices Advisory Committee (ACIP) . MMWR 1991;40:Suppl RR-13:1–25.
Medline37
Evatt
Full Text | Web of Science | Medline38
Johnson
Web of Science | Medline39
Farci
Full Text | Web of Science | Medline40
Choo
CrossRef | Web of Science | Medline41
Marcus R, Bell DM, Culver DH, Cooperative Emergency Department Study Group. Frequency of emergency care providers' contact with blood of patients infected with human immunodeficiency virus. Presented at the Annual Meeting of the Society for Academic Emergency Medicine, Minneapolis, May 22, 1990.
42
Wears
CrossRef | Web of Science | Medline43
Guidelines for prevention of transmission of human immunodeficiency virus and hepatitis B virus to health-care and public-safety workers . MMWR 1989;38:Suppl S-6.
44
Jovanovich
CrossRef | Web of Science | Medline45
Dienstag
Web of Science | Medline46
Update on hepatitis B prevention . MMWR 1987;36:353–66.
Medline47
Alexander
Web of Science | Medline48
Schlipkoter
CrossRef | Web of Science | Medline49
Kiyosawa
Web of Science | Medline50
Seeff
Web of Science | Medline51
Ahtone
CrossRef | Web of Science52
Mayo-Smith
CrossRef | Web of Science | Medline53
Werner
CrossRef | Web of Science | Medline54
Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures . MMWR 1991;40:Suppl RR-8:1–9.
Medline
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CrossRef11
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B. L. Pearlman. (2006) Hepatitis C Virus Infection in African Americans. Clinical Infectious Diseases 42:1, 82-91
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CrossRef21
G. Y. Minuk, A. J. Cohen, N. Assy, M. Moser. (2005) Viral hepatitis and the surgeon. HPB: Official Journal of The International Hepato Pancreato Biliary Association 7:1, 56-64
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Markus Backmund, Kirsten Meyer, Claudia Henkel, Jens Reimer, Martin Wächtler, Christian G. Schütz. (2005) Risk Factors and Predictors of Human Immunodeficiency Virus Infection among Injection Drug Users. European Addiction Research 11:3, 138-144
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Winifred L. Boal, Thomas Hales, Clara Sue Ross. (2005) Blood-Borne Pathogens among Firefighters andEmergency Medical Technicians. Prehospital Emergency Care 9:2, 236-247
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Timothy R Wolfe, Tony Bernstone. (2004) Intranasal Drug Delivery: An Alternative to Intravenous Administration in Selected Emergency Cases. Journal of Emergency Nursing 30:2, 141-147
CrossRef26
Margaret E. Hansen, Subcommittee Chair, Curtis W. Bakal, G. David Dixon, David J. Eschelman, Keith M. Horton, Michael Katz, Eric W. Olcott, David Sacks. (2003) Guidelines Regarding HIV and Other Bloodborne Pathogens in Vascular/Interventional Radiology. Journal of Vascular and Interventional Radiology 14:9, S375-S384
CrossRef27
Stuart C. Gordon. (2003) New insights into acute hepatitis C. Gastroenterology 125:1, 253-256
CrossRef28
M. Victoria Marx. (2003) Hepatitis C Virus Risk in the Interventional Radiology Environment. Journal of Vascular and Interventional Radiology 14:2, 129-131
CrossRef29
Vincenzo Baldo, Annarosa Floreani, Luigino Dal Vecchio, Marco Cristofoletti, Maristella Carletti, Silvia Majori, Angela Di Tommaso, Renzo Trivello. (2002) Occupational Risk of Blood‐Borne Viruses in Healthcare Workers: A 5‐Year Surveillance Program • . Infection Control and Hospital Epidemiology 23:6, 325-327
CrossRef30
M. I. Memon, M. A. Memon. (2002) Hepatitis C: an epidemiological review. Journal of Viral Hepatitis 9:2, 84-100
CrossRef31
Kelly A. McGarry, Michael D. Stein, Jennifer G. Clarke, Peter D. Friedmann. (2002) Utilization of Preventive Health Services by HIV-Seronegative Injection Drug Users. Journal of Addictive Diseases 21:2, 93-102
CrossRef32
Laura M. Lee, David K. Henderson. (2001) Emerging viral infections. Current Opinion in Infectious Diseases 14:4, 467-480
CrossRef33
Jagdeep Obhrai, Yoshio Hall, B. S. Anand. (2001) Assessment of Fatigue and Psychologic Disturbances in Patients with Hepatitis C Virus Infection. Journal of Clinical Gastroenterology 32:5, 413-417
CrossRef34
Antje Knöll, Magdalena Helmig, Ove Peters, Wolfgang Jilg. (2001) Hepatitis C Virus Transmission in a Pediatric Oncology Ward: Analysis of an Outbreak and Review of the Literature. Laboratory Investigation 81:3, 251-262
CrossRef35
ROBERT W. HALEY, R. PAUL FISCHER. (2001) Commercial Tattooing as a Potentially Important Source of Hepatitis C Infection. Medicine 80:2, 134-151
CrossRef36
Anthony J. Chambers, Reginald S. A. Lord. (2001) Documented prevalence of HIV and Hepatitis C infection in patientswith penetrating trauma. ANZ Journal of Surgery 71:1, 21-23
CrossRef37
Gary B. Green, Erik Dehlinger, Thai S. McGrievey, Dai J. Li, Kerrie A. Jones, Gabor D. Kelen, Daniel W. Chan. (2000) CK-MB isoforms for early risk stratification of emergency department patients. Clinica Chimica Acta 300:1-2, 57-73
CrossRef38
Gary B. Green, George W. Skarbek-Borowski, Daniel W. Chan, Gabor D. Kelen. (2000) Myoglobin for Early Risk Stratification of Emergency Department Patients with Possible Myocardial Ischemia. Academic Emergency Medicine 7:6, 625-636
CrossRef39
Hugo R. Rosen. (2000) Primer on Hepatitis C for Hospital Epidemiologists • . Infection Control and Hospital Epidemiology 21:3, 229-234
CrossRef40
David L. Thomas. (2000) Hepatitis C epidemiology: Injecting new tools in the field. Hepatology 31:3, 790-791
CrossRef41
Edward L. Murphy, Stephen M. Bryzman, Simone A. Glynn, Dannie I. Ameti, Ruth A. Thomson, Alan E. Williams, Catharie C. Nass, Helen E. Ownby, George B. Schreiber, Fanhui Kong, Keith R. Neal, George J. Nemo. (2000) Risk factors for hepatitis C virus infection in United States blood donors. Hepatology 31:3, 756-762
CrossRef42
Mark P. Epstein, Tamsin Knox. (2000) Current views on hepatitis C virus infection. Current Infectious Disease Reports 2:1, 55-60
CrossRef43
Gregory J. Moran. (2000) Emergency department management of blood and body fluid exposures. Annals of Emergency Medicine 35:1, 47-62
CrossRef44
Henry David Abraham, Silvia Degli-Esposti, Louis Marino. (1999) Seroprevalence of Hepatitis C in a Sample of Middle Class Substance Abusers. Journal of Addictive Diseases 18:4, 77-87
CrossRef45
David M. Weinstock, Samuel Merrick, Sharp Abdel Malak, Jonathan Jacobs, Kent A. Sepkowitz. (1999) Hepatitis C in an urban population infected with the human immunodeficiency virus. AIDS 13:18, 2593
CrossRef46
El-Serag, Hashem B., Mason, Andrew C., . (1999) Rising Incidence of Hepatocellular Carcinoma in the United States. New England Journal of Medicine 340:10, 745-750
Full Text47
Bradley Evanoff, Lynn Kim, Sunita Mutha, Donna Jeffe, Carolyn Haase, Debbie Andereck, Victoria Fraser. (1999) Compliance With Universal Precautions Among Emergency Department Personnel Caring for Trauma Patients. Annals of Emergency Medicine 33:2, 160-165
CrossRef48
Deniz Akduman, Lynn E. Kim, Rodney L. Parks, Paul B. L’Ecuyer, Sunita Mutha, Donna B. Jeffe, Bradley A. Evanoff, Victoria J. Fraser. (1999) Use of Personal Protective Equipment and Operating Room Behaviors in Four Surgical Subspecialties: Personal Protective Equipment and Behaviors in Surgery • . Infection Control and Hospital Epidemiology 20:2, 110-114
CrossRef49
Elliott S. Greene, Arnold J. Berry, Janine Jagger, Eileen Hanley, William P. Arnold, Melinda K. Bailey, Morris Brown, Patricia Gramling-Babb, Anthony N. Passannante, Joseph L. Seltzer, Peter Southorn, Martha A. Van Clief, Richard A. Venezia. (1998) Multicenter Study of Contaminated Percutaneous Injuries in Anesthesia Personnel. Anesthesiology 89:6, 1362-1372
CrossRef50
Gary B. Green, Dai J. Li, Edward S. Bessman, Jennifer L. Cox, Gabor D. Kelen, Daniel W. Chan. (1998) The Prognostic Significance of Troponin I and Troponin T. Academic Emergency Medicine 5:8, 758-767
CrossRef51
CAROLINE A. SABIN. (1998) Hepatitis C Virus and HIV Coinfection. AIDS Patient Care and STDs 12:3, 199-207
CrossRef52
Adrian M Di Bisceglie. (1998) Hepatitis C. The Lancet 351:9099, 351-355
CrossRef53
HERVÉ ZYLBERBERG, STANISLAS POL. (1998) Characteristics and Treatment of Hepatitis C Virus Infection in HIV-Coinfected Subjects. AIDS Patient Care and STDs 12:1, 11-19
CrossRef54
Josiah D. Rich, Peter V. Chin-Hong, Kimberly A. Busi, Kenneth H. Mayer, Timothy P. Flanigan. (1997) Hepatitis C and HIV in Male Prisoners. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 16:5, 408-409
CrossRef55
Margaret E. Hansen, Curtis W. Bakal, G. David Dixon, David J. Eschelman, Keith M. Horton, Michael Katz, Eric W. Olcott, David Sacks. (1997) Guidelines Regarding HIV and Other Bloodborne Pathogens in Vascular/Interventional Radiology
. Journal of Vascular and Interventional Radiology 8:4, 667-676
CrossRef56
Denise M. Cardo, David M. Bell. (1997) BLOODBORNE PATHOGEN TRANSMISSION IN HEALTH CARE WORKERS. Infectious Disease Clinics of North America 11:2, 331-346
CrossRef57
Andrej Michalsen, George L. Delclos, Sarah A. Felknor, Anthony L. Davidson, Philip C. Johnson, Donald Vesley, Lawrence R. Murphy, Gabor D. Kelen, Robyn R.M. Gershon. (1997) Compliance with Universal Precautions Among Physicians. Journal of Occupational & Environmental Medicine 39:2, 130-137
CrossRef58
DAVID M. NOVICK, KEVIN J. REAGAN, T. SCOTT CROXSON, ALVIN M. GELB, RICHARD J. STENGER, MARY JEANNE KREEK. (1997) Hepatitis C virus serology in parenteral drug users with chronic liver disease. Addiction 92:2, 167-171
CrossRef59
(1996) What is the risk of acquiring hepatitis C for health care workers and what are the recommendations for prophylaxis and follow-up after occupational exposure to hepatitis C virus?. American Journal of Infection Control 24:5, 411-415
CrossRef60
Vincent Agnello, Paul L. Romain. (1996) MIXED CRYOGLOBULINEMIA SECONDARY TO HEPATITIS C VIRUS INFECTION. Rheumatic Disease Clinics of North America 22:1, 1-21
CrossRef61
G Mathé. (1996) Will killing the last HIV1 particle cure AIDS patients? Doesn't CMV activation and/or a graft-versus-host component of the disease, also have to be considered? I. First of two parts. Biomedicine & Pharmacotherapy 50:5, 185-206
CrossRef62
Jonathan A. Patz, David Jodrey. (1995) OCCUPATIONAL HEALTH IN SURGERY: RISKS EXTEND BEYOND THE OPERATING ROOM. ANZ Journal of Surgery 65:9, 627-629
CrossRef63
DAVID L. THOMAS, DAVID VLAHOV, LIZA SOLOMON, SYLVIA COHN, ELLEN TAYLOR, RICHARD GARFEIN, KENRAD E. NELSON. (1995) Correlates of Hepatitis C Virus Infections among Injection Drug Users. Medicine 74:4, 212-220
CrossRef64
C. J. Tibbs. (1995) Methods of transmission of hepatitis C. Journal of Viral Hepatitis 2:3, 113-119
CrossRef65
Keith Henry, Scott Campbell, Phyllis Collier, Carol O'Boyle Williams. (1994) Compliance with universal precautions and needle handling and disposal practices among emergency department staff at two community hospitals. American Journal of Infection Control 22:3, 129-137
CrossRef66
Louise J. Short, David M. Bell. (1993) Risk of occupational infection with blood-borne pathogens in operating and delivery room settings. American Journal of Infection Control 21:6, 343-350
CrossRef67
(1992) Hepatitis B in the Emergency Department. New England Journal of Medicine 327:14, 1032-1032
Full Text68
Quinn, Thomas C., . (1992) Screening for HIV Infection — Benefits and Costs. New England Journal of Medicine 327:7, 486-488
Full Text
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