Correspondence

Risks to Health Care Workers in Developing Countries

N Engl J Med 2001; 345:1916December 27, 2001

Article

To the Editor:

The article by Sagoe-Moses et al. on the risks to health care workers in developing countries (Aug. 16 issue)1 could not be more pertinent. As one of many volunteers with the Malawi Orthopaedic Project, I worked in a program to train 10 clinical officers a year in the care of orthopedic problems commonly seen in developing countries, most of which involve skeletal trauma. In Malawi, where the human immunodeficiency virus (HIV) has been estimated to infect 30 percent of the population, it soon became obvious that protection against self-inoculation was a critical part of the clinical officers' training. Using guidelines developed by the American Academy of Orthopaedic Surgeons, we markedly improved awareness of proper self-protective surgical techniques. Since puncture-resistant gloves and isolation scrub suits are economically unrealistic in operating rooms where the norm is to reuse whatever gloves are available, no-touch techniques in the handling of compound fractures and methods to control the aerosol from surgical lavage are useful addenda to self-protection techniques for those who are learning surgery.

Health care volunteers who travel to countries with horrific rates of HIV and hepatitis C virus infection can help teach surgical techniques that will decrease the risk of accidental self-inoculation.

Charles Peter Goodnough, M.D.
Mary Imogene Bassett Hospital, Cooperstown, NY 13326
pgoodno@hotmail.com

1 References

1. 1

   Sagoe-Moses C, Pearson RD, Perry J, Jagger J. Risks to health care workers in developing countries. N Engl J Med 2001;345:538-541
   Full Text | Web of Science | Medline

To the Editor:

Sagoe-Moses et al. describe the lack of resources for prophylaxis after occupational needle-stick injuries in developing countries. An important related problem is the risk to health care workers and students who travel from developed countries to developing countries. We recently implemented a program to provide medical students from our institution with a supply of antiretroviral medication to be used in the event of a high-risk exposure to HIV while they are training in developing countries.1 Fortunately, no student has had to use the medication so far.

Issues with the use of postexposure prophylaxis in this setting include the expense of such treatment, the education of students about how and when to use it, access to expert consultation in the event of a possible exposure, and the security and storage of the medication abroad. Postexposure prophylaxis is covered by a special health fee paid by all medical students. To keep costs down, only one week's worth of medication is sent with each student, and thus a student might have to end his or her rotation in a developing country early in order to complete evaluation and treatment. An additional issue is that students may need to take gloves and sterile needles with them.

Esther S. Tanzman, M.D.
Ralph A. Manchester, M.D.
University of Rochester School of Medicine and Dentistry, Rochester, NY 14642
rmanchester@uhs.rochester.edu

1 References

1. 1

   Updated U. S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR Morb Mortal Wkly Rep 2001;50:1-52
   Medline

Author/Editor Response

The authors reply:

To the Editor: Goodnough and Tanzman and Manchester raise important issues. It is surely a responsible policy to provide medical students and other health care workers with supplies of antiretroviral medication before they travel to developing countries, in case of a high-risk exposure to HIV. But this also raises a troubling ethical issue for such health care workers: should they share this medication with their colleagues abroad, who may also be exposed to HIV, or should they withhold it?

The prohibitive expense of postexposure follow-up and chemoprophylaxis will continue to make prevention the primary strategy for protecting health care workers in developing countries from exposure to blood-borne pathogens. The orthopedic project in Malawi, described by Goodnough, presents an excellent opportunity for implementing effective and affordable prevention measures. Sharp-tip suture needles cause the majority of injuries in operating room personnel,1 but blunt-tip suture needles are available that are equivalent in cost, do not cause needle-stick injuries, and can be used for suturing most internal tissues, such as muscle, fascia, fat, and liver.2 In addition, hands-free passing of sharp instruments has been shown to reduce the incidence of injury during certain types of surgery.3 This technique requires training but incurs no direct cost. These are just two examples of feasible strategies that may reduce injuries from sharp instruments but that have yet to be implemented in developing countries.

A systematic assessment of preventive methods is needed to determine which methods can be immediately applied in developing regions, what further product development is needed for affordable protective measures, and what funding mechanisms can be used to support the most critical prevention needs. Implementing appropriate devices and techniques to prevent exposure to blood-borne pathogens in developing countries will protect not only the health care workers in those countries but also the workers from industrialized countries who come to train or assist them or to learn from them.

Charles Sagoe-Moses, M.D.
Ministry of Health, Accra, Ghana

Richard D. Pearson, M.D.
Jane Perry, M.A.
Janine Jagger, M.P.H., Ph.D.
University of Virginia Health System, Charlottesville, VA 22908-0764
jcj@virginia.edu

3 References

1. 1

   Jagger J, Bentley M, Tereskerz P. A study of patterns and prevention of blood exposures in OR personnel. AORN J 1998;67:979-996
   CrossRef | Medline

2. 2

   Evaluation of blunt suture needles in preventing percutaneous injuries among health-care workers during gynecologic surgical procedures -- New York City, March 1993-June 1994. MMWR Morb Mortal Wkly Rep 1997;46:25-29
   Medline

3. 3

   Stringer B, Infante-Rivard C, Hanley J. A prospective study of the effectiveness of use of the hands-free technique, a recommended work practice. Infect Control Hosp Epidemiol 2000;21:112-112 abstract.