What is the Risk of HIV Transmission from an Inanimate Object?

Patient Presentation
A 23-month-old male’s mother called to the clinic after she had found her son holding a single razor blade near a garbage can in a park. He dropped the blade and the mother immediately checked his hands. She says that he appeared to have no cuts or scratches on his hands or other body parts. She immediately used an alcohol-based hand sanitizer gel on his hands to wash them, then brought him home and washed his hands with soap and water. She had picked the razor blade up herself with tissue and discarded it after wrapping it in several other layers of tissue and putting it into an open tin can in the trash. She was now calling because she was worried that he might contract Human Immunodeficiency Virus. The resident taking the phone call ascertained that he did not have any area of his skin where it was broken such as a hang-nail, or rash, that he was otherwise well and that he was current with his immunizations. The mother said that the razor blade was triangular and looked more like a utility razor blade than a rectangular single- or double-sided blade used for shaving. She also noted that it had some rust on it. The diagnosis of a potential exposure to a blood-borne infection was made. After talking with her attending physician, the resident counseled the mother that as the child had intact skin, it was very unlikely that any contagion had been passed from the razor blade to the child. The child also had an extra layer of protection as he had been immunized for tetanus and Hepatitis B. HIV and Hepatitis C were potential risks but felt to be very low given the circumstances. The mother was comfortable with this and said she would call if she saw any skin cuts that she hadn’t seen before.

Discussion
Blood-borne infections are always a risk for anyone. Some occupations pose higher risks than others such as health care workers, emergency responders, public safety personnel, sex-trade workers and body art professionals. These workers can be exposed to body fluids by sharps, mucous membrane and skin exposures. Personal safety equipment and universal precautions should be utilized properly, consistently every time there is the possibility of an exposure. Accidental exposures still occur and the CDC has recommendations for proper management and possible post-exposure prophylaxic medication use. The main concerns are for Hepatitis B, Hepatitis C and human immunodeficiency virus (HIV).

Learning Point
HIV basically cannot survive outside the human body for long. The main transmission risk is from direct contact with infectious fluids. Drying of fluids dramatically decreases the infectivity. In laboratory studies with high concentrations of HIV, the amount of live virus was reduced to 90-99% after a few hours. The initial high concentrations were more than the usual concentration within a human body. Therefore, once the body fluid is dry, the risk of transmission is essentially zero.

One concern with medical needles is that the fluid within the hollow needle may not be dried, and therefore would contain live virus.

Questions for Further Discussion
1. What are the risks of death by traveling in a car, motorcycle or airplane?
2. What are the potential health risks for receiving a tattoo or body piercing?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: HIV/AIDS

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Centers for Disease Control. HIV and AIDS: Are You at Risk? Available from the Internet at http://www.cdc.gov/hiv/resources/brochures/at-risk.htm (rev. 8/1/2007, cited 4/18/2011).

Centers for Disease Control. Bloodborne Infectious Diseases: HIV/AIDS, Hepatitis B, Hepatitis C. Available from the Internet at http://www.cdc.gov/niosh/topics/bbp/ (rev. 10/27/2010, cited 4/18/2011).

Centers for Disease Control. Hepatitis C FAQs for Health Professionals. Available from the Internet at http://www.cdc.gov/hepatitis/HCV/HCVfaq.htm (rev. 12/17/2010, cited 4/11/2011).

Centers for Disease Control. Hepatitis B FAQs for Health Professionals. Available from the Internet at http://www.cdc.gov/hepatitis/HBV/HBVfaq.htm (rev. 4/4/11, cited 4/18/11).

University of San Francisco. HIVInSite. Can HIV Survive Outside the Body: Is This a Hoax? Available from the Internet at http://hivinsite.ucsf.edu/insite?page=ask-05-11-09 (cited 4/18/2011).

Personal phone call. CDC-INFO. 1-800-CDC-INFO (232-4636). 4/18/2011.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

    sitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • How Common Is An Incarcerated Umbilical Hernia?

    Patient Presentation
    A 3-month-old female came to clinic with 2-3 days of diarrhea described as watery, yellow, without blood or mucous. She had emesis of formula only with at least 1/2 the feeding that is non-projectile. Her mother also noted that her umbilical hernia seems to be “turning blue” once in a while. She has been fussy the past 2-3 days but has been eagerly eating and is urinating well. Children at daycare have had diarrhea recently also. The past medical history is non-contributory. The review of systems shows no fever or upper respiratory tract infection symptoms, and she has a gluteal rash. The pertinent physical exam shows a slightly fussy female with normal vital signs and growth parameters in the 25-90%. She has gained weight from her 2 month appointment. Her abdominal examination shows an umbilical hernia of approximately 0.75 cm internal diameter ring with mild bluish coloring mainly at the ring. It was unable to be reduced. She had increased bowel sounds, but no organomegaly. Her diaper area showed a contact dermatitis rash.

    The diagnosis of probably gastroenteritis with a possible incarcerated umbilical hernia was made. A laboratory evaluation of a basic metabolic profile was normal. The radiologic evaluation of an abdominal radiograph showed small bowel with distension, but no obvious obstructive pattern. A surgeon was consulted who, with great pressure, reduced the umbilical hernia. The patient was discharged home with instructions for treatment of gastroenteritis, but to return if the umbilical hernia reappeared, emesis or diarrhea increased or if the patient seemed to be overall worse. At her 4 month appointment, the patient was doing well.

    Case Image
    Figure 93 – Lateral radiograph of the abdomen shows an umbilical hernia with a loop of bowel trapped within it.

    Discussion
    Umbilical hernias are commonly seen in pediatric patients. They usually are markedly improved by 1 year of age, and should be gone by 4-5 years of age. Hernias at this time are often repaired for cosmesis and to decrease the risk of incarceration often in adulthood. Usually abdominal contents or fluid that lie within the hernia’s pouch are easily reduced with very minimal pressure. A review of umbilical masses can be found here.

    Incarcerated umbilical hernias are much more common in adults who have underlying reasons for increased abdominal presure including pregnancy, cirrhosis, abdominal transplantations, paracentesis, obesity and a variety of benign and malignant tumors.

    Learning Point
    Incarceration of umbilical hernias in children is uncommon to rare in the literature. In 1997, Vransky reviewed the literature and found 45 cases, and another paper reported 1 case. In 1998 one paper reported an additional 4 cases and in 1999 a fourth paper described 1 more. In 2006, Chirdan described 23 additional cases. While this is not a full systemic review of the literature, it appears that for the past ~ 80 years, less than 100 cases have been reported in the literature of incarcerated umbilical hernias.

    It is important to note, that just because the literature does not report cases, does not mean that the incidence is necessarily low because the literature depends on individuals to report the cases and editors to publish the manuscripts. In both of his reports Vransky notes “… we believe that [umbilical hernia] incarceration is much more frequent than is generally supposed, and we report our plea for a more active therapeutic approach… especially in smaller [umbilical hernias] where incarceration is more probable.”

    Questions for Further Discussion
    1. How common are incarcerated inguinal hernias?
    2. How are umbilical hernias formed?
    3. What are the potential complications of laproscopic surgery involving the umbilicus?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Hernias

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Vrsansky P, Bourdelat D. Incarcerated umbilical hernia in children. Pediatr Surg Int. 1997;12(1):61-2.

    Simon HK. Radiological case of the month. Incarcerated umbilical hernia. Arch Pediatr Adolesc Med. 1997 May;151(5):519-20.

    Papagrigoriadis S, Browse DJ, Howard ER. Incarceration of umbilical hernias in children: a rare but important complication. Pediatr Surg Int. 1998 Dec;14(3):231-2.

    Vrsansky P. Incarcerated umbilical hernia in children: Comment. Pediatr Surg Int. 1999;15(7):527.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Are Indications for Pelvic Examinations in Adolescents?

    Patient Presentation
    A 16-year-old female came to clinic for her health maintenance examination. She had become sexually active in the past year with one partner. She did not anticipate being sexually active in the near future but she and her mother wanted to discuss options for possible birth control and sexually transmitted infection (STI) prophylaxis. She denied any gynecological problems. The resident did initial counseling with the adolescent but was unsure what, if any, testing needed to completed at this time.

    The pertinent physical exam showed a healthy appearing adolescent female with growth parameters in the 10-50% and normal vital signs. Her general examination was normal including Tanner V staging and a normal external genital examination. The diagnosis of a healthy adolescent was made. During staffing, the attending physician also said that he was unclear if she needed a pelvic examination at this time because the guidelines had recently changed. Together they looked up the guidelines on the Internet and found that a pelvic examination was not indicated until she was 21 years of age. The adolescent and her mother were counseled that STI testing should be considered but that a pelvic examination was not needed at this time. The adolescent stated that she had used condoms and spermicidal jelly but she agreed to urine STI testing that eventually was negative. The adolescent was still unsure about initiating birth control, so additional handouts and website references were given to her.

    Discussion
    In 2010, the American College of Obstetricians and Gynecologists changed the recommendations for Papanicolaou (Pap) testing. The first Pap test is at 21 years of age regardless of the onset of sexual activity unless the patient has HIV or is immune suppressed and patients are then followed yearly after initiation of sexual activity. The reasons for this change are that although about 50% of high school students are sexually active, and about 50% of young women will have a positive test for human papilloma virus (HPV) within 36 months of initiating sexual activity, over 90% of the HPV infections will resolve within 24 months in patients with intact immune systems. HPV is the most common STI worldwide.

    Adolescent patients who have previously been screened and have cervical atypia or neoplasia have different recommendations for followup and can be reviewed in To Learn More below.

    Learning Point
    Indications for a pelvic examination are:

    • Bleeding
      • Abnormal vaginal bleeding
      • Menstrual irregularities – amenorrhea, dysmenorrhea that is unresponsive to nonsteroidal anti-inflammatory medication
    • Lower abdominal pain
    • Dysuria or urinary tract symptoms in a sexually active female
    • Vaginal discharge that is persistent
    • Pregnancy
    • Papanicolaou (Pap) test
    • Intrauterine device or diaphragm contraception initiation and use
    • Suspected or reported sexual abuse or rape

    Questions for Further Discussion
    1. What are indications for referral to a gynecologist?
    2. How common is adolescent pregnancy and what are its risks?
    3. How common are STIs in adolescents?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Women’s Health Checkup and Teen Sexual Health.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 463: Cervical cancer in adolescents: screening, evaluation, and management. Obstet Gynecol. 2010 Aug;116(2 Pt 1):469-72.

    Braverman PK, Breech L; Committee on Adolescence. American Academy of Pediatrics. Clinical report–gynecologic examination for adolescents in the pediatric office setting. Pediatrics. 2010 Sep;126(3):583-90.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
    16. Learning of students and other health care professionals is facilitated.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital