International Journal of Surgery Science 2020; 4(3): 341-344

E-ISSN: 2616-3470
P-ISSN: 2616-3462
© Surgery Science Epidemiology of HIV, Hepatitis B and C virus in
www.surgeryscience.com
2020; 4(3): 341-344 emergency and elective surgical patients: Our
Received: 09-06-2020
Accepted: 13-07-2020
experience of 275 patients in a single surgical ward
Pal Naresh
Professor, Department of Surgery
Pal Naresh, Kumar Ritesh, Jangra Amit and Gyaltsen Paden Dechen
Pt. B D Sharma PGIMS, Rohtak,
Haryana India DOI: https://doi.org/10.33545/surgery.2020.v4.i3f.517
Kumar Ritesh Abstract
Senior Resident, Department of Human immunodeficiency, hepatitis B and hepatitis C virus are major health problems throughout the world.
Surgery, Pt. B D Sharma PGIMS,
All over the world surgeons have the highest risk for exposure to blood and its products during performing
Rohtak, Haryana India
their procedures. Human immunodeficiency, hepatitis B and hepatitis C affecting more than three billion
Jangra Amit people worldwide and hepatitis B and hepatitis C virus is the single most important factor of chronic liver
Junior Resident, Department of disease and hepato-cellular carcinoma in India and abroad. Universally preoperative testing of these blood
Surgery, Pt. B D Sharma PGIMS, born virus HIV, HBV, HCV has been a accepted strategy to reduce the risk of virus transmission. This study
Rohtak, Haryana, India was designed to analyse the magnitude of these infections as a global health problem, affecting millions of
population throughout globe. This study also describe the prevalence of Human Immunodeficiency Virus,
Gyaltsen Paden Dechen Hepatitis B and Hepatitis C virus in surgical patients undergoing elective and emergency surgeries.
Junior Resident, Department of Material and Methods: This is a retrospective study done on 275 patients who were admitted for general
Surgery, Pt. B D Sharma PGIMS, surgical care between July 2016 and May 2020 in single surgical ward and were positive for HBsAg, anti-
Rohtak, Haryana India HCV, and anti-HIV antibodies.
Results: Patients included in the study were between 16-18 years of age and included both male as well as
female. There were 182 male and 93 female with male: female ratio 1: 0.51. Out of 275 patients 33.45%
patients were positive for HBsAg, 34.54% were positive for anti-HCV, and 29.09% were positive for anti-
HIV.
Conclusions: Education of all healthcare workers including doctors along with routine preoperative testing
of all patients undergoing elective and emergency surgeries are highly important to enhance the awareness
of these infection in order to reduce the transmission of disease. As the common message is ‘Prevention is
better than cure ‘It is highly important to prevent further spread of these infections by screening of every
patient before any surgery whether elective or emergency and also counselling should be done of all patients.
All the doctors and paramedical staff must follow the proper ethical practice to ensuring the use of sterile
disposables in all these patients where indicated and also protecting themselves from these viral infections.

Keywords: HIV, Hepatitis-B, Hepatitis-C, screening, surgical patients

Introduction
Hepatitis B virus (HBV), Hepatitis C virus (HCV) and Human Immunodeficiency Virus (HIV)
are the prime causes of morbidity among the viral infections which may lead to mortality also.
These virus can be transmitted through a common route and hence can be transmitted
simultaneously [1, 2]. Prevalence of HBV, HCV and HIV can be estimated by Serological surveys
which may help to develop long term strategies for improving the public health standards. The
HBV infection is a worldwide issue, and 66 per cent global population resides in the areas with
higher prevalence of infections. Surgeons are prone to HBV infection with the annual incidence
50 times more than that of general population and twice that of physicians [3] Hepatitis C is a
contagious liver disease caused by HCV. Every year 3-4 million people are infected with the
hepatitis C [4]. Causative agent of acquired immunodeficiency deficiency syndrome (AIDS) is
human immunodeficiency virus (HIV) which is a retrovirus. HIV makes the host vulnerable to
lethal opportunistic infections for life long. According to the data provided by WHO in 2015,
86,300 new HIV infections were detected and total 2.1 million people were having HIV infections
Corresponding Author in India. The prevalence of HIV in India (2015) in 15-49 years was 0.26 percent with 0.30 percent
Pal Naresh
Professor, Department of Surgery in males and 0.22 percent in females [5].
Pt. B D Sharma PGIMS, Rohtak,
Haryana India

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Healthcare workers have risk of acquiring blood borne infections and emergency operations including patients for conservative
and surgeons are more prone as compared to other health care management positive for HIV, HEPATITIS B and HEPATITIS
workers due to increased exposure to blood and percutaneous C. Out of 275 patients 182 (66.18%) were males and 93(33.81%)
injuries [6, 7]. In 2000 as a result of percutaneous injuries 16,000 were females as shown in table 1.
HCV; 66,000 HBV and 1000 HIV infections were developed in
healthcare workers. 8 Selecting good screening tests taking Table 1: Sex Distribution of Patients
adequate precautions and proper disposal of biomedical waste can Male (n=275) Female (n=275)
help in reducing transmission of these viral infections. 183 (66.18%) 93 (33.81%)

Material and Methods: This is a retrospective study done on 275 The male to female ratio was 1:0.51. The age of these patients was
patients who were admitted for general surgical care between July between 15 to 86 years. Fifteen year female was the youngest
2016 and May 2020 in single surgical ward positive for HBsAg, patient admitted after multiple injuries. The oldest patient was 86
anti-HCV, and anti-HIV antibodies. The study includes all the year male operated for peptic perforation.
general surgical patients who were admitted for emergency,
elective surgery or for conservative management through accident Table 2: Age Group distribution of both male and female patients
and emergency and from outdoor clinics. In all patients
preoperative blood samples were sent for testing for these three Age in years Male Female Total (n=275 % Age)
virus to microbiology department. Detail history was recorded for ≤ 20 6 2 8 02.90
21-30 39 19 58 21.09
all patient, like age, sex, type of surgery needed, weather elective
31-40 48 17 65 23.66
or emergency surgery and other relevant blood investigations
41-50 42 22 64 23.27
including pre-anaesthetic check-up for operative patients. Patients 51-60 28 21 49 17.81
having seropositivity for HIV, HBV and HCV are referred to ≥ 60 19 12 31 11.27
physician for counselling and further management For HIV and
AIDS patients were referred to ART centre of our institute, for As per table 2 least number of patients were in age group of up to
confirmation, counselling. twenty years 8(2.90%). Maximum patients were in age group of
31-40 years 65 patients (23.66%). Male patients
Results were also highest in this age group. Female patients were highest
Two hundred seventy five (275) patients were admitted in in age group of 41-50 years.
General Surgical ward during a period of four years for elective

Table 3: Positivity for HBsAg, anti-HCV, and anti-HIV.

Male Female Total % Age(n=275)
HBsAg 63 29 92 33.45
HCV 57 38 95 34.54
HIV 56 24 80 29.09
HIV +HBsAg 5 1 6 02.18
HIV +HCV 1 1 2 00.72

The preoperative prevalence of HBV, HCV and HIV in the prevalence, people having HIV and haemodialysis recipients
present study was significantly higher in males 63, 57, 56 form the major disease burden are at higher risk of having HBV
respectively than in females 29, 38, 24 respectively. In total HCV as reported in European countries. [14]. Population groups like
has highest prevalence seen in (34.54%) patients. Five male people in prison, haemodialysis recipients, people living with
patients were positive both for HIV and HBV and one patient was HIV, blood transfusion recipients, tissue recipients and diabetics
positive for HIV and HCV. One each female patient was positive are considered at increased risk or having higher burden of HCV
[14]
for HIV and HBV and another for HIV and HCV. .
A certain group of people have increased exposure making them
Discussion vulnerable to increased risk or increased burden of HBV or HCV.
Infection caused by HIV, HBV and HCV present throughout the These groups of people include tattoo recipients, sex workers,
world. On the basis of several published thresholds prevalence undergoing medical intervention, waste workers, using anabolic
rates may be defined as > Intermediate HBV and HCV steroids, involved in high risk sexual behaviour, having sexually
prevalence: HBsAg seroprevalence or HCV antibody transmitted disease, using intranasal drugs, travellers, homeless
seroprevalence is between 2% and 5% in general population and and public safety workers [14].
High HBV and HCV prevalence is ≥5% [9]. The prevalence for Early diagnosis of HBV, HCV and HIV not only provides benefits
HIV is high when it exceeds 1% in general population [10]. Several to people infected but also contributes to better public health. It
targets have been identified by World Health Organization and allows the infected people to have early access to the treatment.
UNAIDS to eliminate viral hepatitis and HIV as public health Treatment has to be continued lifelong for Hepatitis B which
threats by 2030. These targets include diagnosing the viral suppresses the viral replication in 70 to 80% of recipients. It also
diseases as early as possible, scaling up treatment and minimizing reduces the progression of cirrhosis and development of
the mortality due to these diseases [11, 12]. hepatocellular carcinoma. Treatment of HCV is continued for 8
Sequel to HBV and HCV infections can be acute and chronic to 12-24 weeks achieving cure in more than 90% of the cases [15,
16]
hepatitis, cirrhosis, hepatocellular carcinoma and death. 4.7 . Antiretroviral therapy suppresses the virus in 97 to 98% of
million people are estimated to be chronically infected with HBV people having HIV leading to decreased rate of co-morbid illness
and 3.9 million people are infected with HCV. 13 Population and lower chances of opportunistic infections in future [17, 18].
including migrants from various countries with higher disease Various diagnostic options are available for diagnosing of HBV,

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HCV and HIV. Detailed description of these diagnostic options injury. Other routes of transmission include sexual contact or
can be seen in WHO testing guidelines [9, 19]. The recommended vertical transmission from mother to child [29].
threshold in general population for the strategy are based on the In the developing countries most of the deliveries are conducted
intermediate prevalence of HBV/ HCV and the high prevalence in the unhygienic conditions by the traditional birth attendants
of HBV/HCV/HIV. These thresholds as described earlier are making the females more prone to contract HBV and HCV
defined as 2% and 5% for HBsAg seropositivity for HBV and infection. Many quacks and dental practitioners use the same
HCV antibody seropositivity for HCV [8] and 1% positivity for instrument or syringe in more than one patient without proper
HIV [9]. sterilization making the patients vulnerable to contract the HBV
Guidelines of National Institute of Clinical Excellence (NICE) in and HCV infection. Three main factors are significant for the
the United Kingdom has expanded the HIV testing beyond prevalence of the disease (1) intravenous drug abuse (2) blood
antenatal and sexual health settings. Now it also includes transfusion (3) low socioeconomic status [30, 31, 32].
everyone in the areas of high and very high prevalence on hospital Prevalence of HIV, HBV and HCV is common and it is defined
attendance and on registration with general practice. [20]. But no as proportion of a population with specific disease at a certain
evidence of such approach is being followed for HBV and HCV point of time. After taking different circumstances like local
testing is there. Testing strategies may be developed targeting epidemiology into account, testing strategies may be guided to
population having intermediate (>2%) and high prevalence (>5%) classify HCV, HBV and HIV into low, intermediate and high
for HBV and HCV [9]. prevalence rates. Prevention and counselling are the mainstay
As per guidelines by EACS (European AIDS Clinical Society) responses to prevent Hepatitis to become an epidemic. Risks,
and EASL (European Association for the Study of the Liver), all sequel, modes of transmission should be known to both patient as
the patients diagnosed with either of the three virus infection in well as health care workers. Surgical team including surgeon,
hospital settings need to be tested for the other two [21, 22]. In our theatre staff nurse and other health care workers are at higher risk
institute for surgical patients, we are testing for all the three virus of contracting these infections. However as this study is
simultaneously. After surgical problem is over we referred these conducted in a single surgical ward its results cannot be
patients for further management to hepatitis clinic/ ART centre. generalized over the general population regarding the frequencies
Any patient showing clinical symptoms or laboratory tests of HBV and HCV. The frequency of the viral infections is higher
suggestive of acute or chronic hepatitis need to be tested for HBV in our study as compared to those reported in the epidemiological
and HCV according to national and international guidelines. Also studies. However it indicates the increased risk of HCV and
any patient presenting with any condition indicative of HIV, suggests implementing measures to reduce the exposure to
patient should to be referred for HIV testing [23]. healthcare workers.
In the present study of 275 patients males (66.18%) have higher
preoperative prevalence of these virus as compared to females Conclusion
(33.81%). In the study conducted by Mashud I, males (4%) have As higher prevalence of HBsAg and anti HCV was found in
higher preoperative prevalence as compared to females (2%). It preoperative patients, screening of every patient and counselling
may be due to greater social mobility and independence among of the patients should be done. As prevention is better than cure,
males than females in developing countries especially in the rural doctors and other healthcare workers should follow proper ethical
areas which makes males are more prone to contract the infection practice and take adequate precautions and thereby protecting
as compared to females.24 However, in some other studies from themselves and patients from contracting these viral infections.
developing countries females have higher rates of infection than In our study, Hepatitis B virus infection was more prevalent
males [25]. among the study group followed by Hepatitis C virus infection,
Due to higher prevalence of these viruses in the developing Co-infections and HIV. Most affected age group was 21-50years,
countries, preoperative testing may make the entire surgical team in both sexes. 07/70(10%) of affected age group was less than 20
more vigilant to take more precautions during the surgery. years. Awareness campaign, vaccination of family members of
Preoperative serological testing makes the patients aware of their seropositive patients may be a preventive measure. To increase
seropositivity and also helps in early detection of the infection and the awareness among general population active participation of
the associated diseases which would otherwise have gone government and media is required. People should be told about
undetected, hence limiting the spread of virus in the community. safe sexual practices, use of blood and blood products from
Patients in the present study were encouraged to take precautions registered blood banks only and routes of transmission of viruses.
and also referred for further investigations hence limiting the Use of disposable medical consumables and proper disposal of
spread of virus to other individuals. Occupational acquired viral bio-medical waste should be ensured in the medical practice.
infections are more in the developing countries as compared to Post-Exposure prophylaxis as per recommendation will be
the developed countries as health care workers are exposed to a preventive for surgeons, anaesthetists, assistants, nursing staff
population with higher prevalence of blood borne virus infections and all team in health care system.
in the developing countries like Turkey [26].
There are not many studies to assess the prevalence of HBV, HCV Reference
and HIV in the surgical patients. Our study includes 275 patients 1. Lavanchy D. Worldwide epidemiology of HBV infection,
to study the clinical profile and epidemiology of HIV, HBV and disease burden, and vaccine prevention. J Clin Virol. 2005;
HCV infection. Weis et al conducted a study at John Hopkins and 34:S1-3.
reported the prevalence of HCV (35%) and HBV (4%). Ratio of 2. Leone N, Rizzetto M. Natural history of hepatitis C virus
males was more as compared to females. They reported 2.3% infection: from chronic hepatitis to cirrhosis, to
males and 1.3% females in HBV while 7.44% males and 5.36% hepatocellular carcinoma. Miner Gastroenterol Dietol. 2005;
females in HCV [27]. 51:31-46.
The results corroborated with the study conducted by Merik et al. 3. WHO, Fact Sheet Hepatitis B, No. 204, 2016
28 Hepatitis B and C are transmitted mainly by parenteral route 4. WHO, Fact Sheet Hepatitis C, No. 164, 2016
which includes contaminated blood transfusion or needle stick 5. WHO, Country Fact Sheet, HIV/AIDS in India, 2015

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6. Dement JM, Epling C, Ostbye T, Pompeii LA, Hunt DL. Bouvet E, Yazdanpanah Y. Blood-borne viruses in health
Blood and body fluid exposure risks among health care care workers: prevention and management. J Clin Virol.
workers: results from the Duke Health and Safety 2011; 52:4-10.
Surveillance System. Am J Ind Med. 2004; 46:637-48. 27. Weis ES, Makary MA, Wang T, Syin D, Pronovost PJ, Chang
7. Doebbeling BN, Vaughn TE, McCoy KD, Beekmann SE, D et al. Prevalence of blood-borne pathogens in an urban,
Woolson RF, Ferguson KJ et al. Percutaneous injury, blood university-based general surgical practice. Ann Surg 2005;
exposure, and adherence to standard precautions: are 241:803-7.
hospital-based health care providers still at risk? Clin Infect 28. Meri Koulentaki, Maria Ergazaki, Joanna Moschandrea,
Dis. 2003; 37:1006-13. Stelios Spanoudakis, Nikolaos Tzagarakis. Prevalence of
8. Prüss-Ustün A, Rapiti E, Hutin Y. Estimation of the global hepatitis B and C workers in high-risk hospitalised patients
burden of disease attributable to contaminated sharps injuries in Grete. A five-year observational study. BMC Public
among health-care workers. Am J Ind Med. 2005; 48:482-90. Health, 2001; 1:17.
9. World Health Organization. Guidelines on hepatitis B and C 29. Khokhar N, Gill ML, Yawar A. Interspousal transmission of
testing. Geneva: WHO, 2017. Hepatitis C virus. J Coll Physicians Surg Pak 2005; 15:587-
10. World Health Organization. HIV/AIDS: Definition of key 9.
terms. Geneva: WHO, 2013. 30. Bialek SR, Bower WA, Mottram K, Purchase D, Nakano T,
11. World Health Organization. Global health sector strategy on Nainan O, et al. Risk factors for Hepatitis B in an outbreak
viral hepatitis 2016–2021: towards ending viral hepatitis. of hepatitis B and D among injection drug users. J Urban
Geneva: WHO, 2016. Health 2005; 82:468-78.
12. World Health Organization. Global health sector strategy on 31. Yazdanpanah Y, De Carli G, Migueres B, Lot F, Campins M,
HIV, 2016–2021: towards ending AIDS. Geneva: WHO, Colombo C et al. Risk factors for hepatitis C virus
2016. transmission to healthcare workers after occupational
13. Hofstraat SHI, Falla AM, Duffell EF, Hahne SJM, Amato- exposure: A European case-control study. Clin Infect Dis
Gauci AJ, Veldhuijzen IK et al. Current prevalence of 2005; 41:1423-30.
chronic hepatitis B and C virus infection in the general 32. Cholongitas E, Senzolo M, Patch D, Kwong K, Nikolopoulou
population, blood donors and pregnant women in the V, Leandro G et al. Risk factors, sequential organ failure
EU/EEA: a systematic review. Epidemiol Infect. 2017; assessment and model for end-stage liver disease scores for
145(14):2873-85. predicting short term mortality in cirrhotic patients admitted
14. European Centre for Disease Prevention and Control. to intensive care unit. Aliment Pharmacol Ther. 2006;
Hepatitis B and C epidemiology in selected population 23:883-93.
groups in the EU/EEA. Stockholm: ECDC, 2018.
15. World Health Organization. Combating hepatitis B and C to
reach elimination by 2030. Geneva: WHO, 2016.
16. Ward H, Tang L, Poonia B, Kottilil S. Treatment of hepatitis
B virus. Future Microbiol. 2016; 11(12):1581-97.
17. Lundgren J, Babiker A, Gordin F, Emery S, Grund B, Sharma
S et al. Initiation of Antiretroviral Therapy in Early
Asymptomatic HIV Infection. New Engl J Med. 2015;
373(9):795-807.
18. World Health Organization. Consolidated Guidelines on the
Use of Antiretroviral Drugs for Treating and Preventing HIV
Infection: Recommendations for a public health approach -
Second edition. Geneva: WHO, 2016.
19. World Health Organization. Consolidated guidelines on HIV
testing services. Geneva: WHO, 2015
20. National Institute for Health and Care Excellence. HIV
testing: increasing uptake among people who may have
undiagnosed HIV. London: NICE, 2016.
21. European AIDS Clinical Society. HIV guidelines version 9.0.
Brussels: EACS, 2017.
22. European Association for the Study of the Liver. EASL
Recommendations on Treatment of Hepatitis C 2018. J
Hepatol. 2018; 69(2):461-511
23. HIV in Europe. HIV Indicator Conditions: Guidance for
Implementing HIV Testing in Adults in Health Care Settings.
Copenhagen: HIV in Europe, 2012.
24. Mashud I, Khan H, Khattak AM. Relative frequency of
hepatitis B and C viruses in patients with hepatic cirrhosis at
DHQ teaching hospital D. I. Khan. J Ayub Med Coll
Abbottabad. 2004; 16:32-4.
25. Chaudhary I, Khan S, Samiullah. Should we do Hepatitis B
and Hepatitis C screening on each patient before surgery:
analysis of 142 cases. Pak J Med Sci. 2005; 21:278-80.
26. Deuffic-Burban S, Delarocque-Astagneau E, Abiteboul D,

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